IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Photographic 

Sciences 

Coiporation 


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23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


••  J4.j'8'''iS?SWi3Ri^5!ge3?l! 


AiM 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


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.-,^a^'5^«Siigjs»Xia¥!ssKSSfc'ffi?siS5S,^ssii5Sa.i^^^ 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


L'Institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-6tre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mdthode  normale  de  fiimage 
sont  indiqu6s  ci-dessous. 


D 
D 
D 

n 
n 


n 


D 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagde 

Covers  restored  and/or  laminated/ 
Couverture  restaurde  et/ou  pellicul^e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
P3li6  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  reliure  serr^e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  int^rieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajoutdes 
lors  dune  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  dtait  possible,  ces  pages  n'ont 
pas  6t6  filmdes. 

Additional  comments:/ 
Commentaires  suppl6mentaires; 


D 
D 
D 
D 


D 
D 


Coloured  pages/ 
Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/or  laminated/ 
Pages  restaur^es  et/ou  pellicul^es 

Pages  discoloured,  stained  or  foxed/ 
Pages  d^color^es,  tachetdes  ou  piqu^es 


I      I    Pages  detached/ 


Pages  ddtach^es 

Showthrough/ 
Transparence 

Quality  of  prir 

Quality  indgale  de  I'impression 

Includes  supplementary  materii 
Comprend  du  materiel  supplementaire 


r~n    Showthrough/ 

I      I    Quality  of  print  varies/ 

I      I    Includes  supplementary  material/ 


Only  edition  available/ 
Seule  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure. 
etc.,  ont  6t6  film6es  d  nouveau  de  fagon  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film6  au  taux  de  reduction  indiqu6  ci-dessous. 

14X  18X  22X 


10X 


26X 


SOX 


2 


] 


12X 


16X 


20X 


24X 


28X 


Wi. 


.*^■if>jy^i^^.^i:ti.4^'f^^ii;l«SSW■^^ 


■..:r**'»n*!i*^l*»*-*T;%jfe?ffl 


Is 

J 

ifier 

le 

ige 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Library  of  Congress 
Photoduplication  Service 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ►  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plater,,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


L'axemplaire  film*  fut  reproduit  grAce  d  la 
gAnArositA  de: 

Library  of  Congress 
Photoduplication  Service 

Les  images  suivantes  ont  6tA  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
da  la  nettet*  de  I'exemplaire  film6,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimAe  sont  filmis  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
darniAre  page  qui  comporte  une  empreinte 
d'imprassion  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  film6s  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'imprassion  ou  d'illustration  et  en  terminant  par 
la  dernlAre  page  qui  comporte  une  teile 
empreinte. 

Un  des  symboles  suivants  apparaltra  sur  la 
darniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  —^  signifie  "A  SUIVRE",  le 
symbole  ▼  signifie  "FIN  ". 

Las  cartas,  planches,  tableaux,  etc.,  peuvent  dtre 
filmis  A  des  taux  de  reduction  diffirents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  cliche,  il  est  film6  d  partir 
da  Tangle  supArieur  gauche,  de  gauche  d  droite, 
et  da  haut  en  bas,  en  prenant  le  nombre 
d'images  ntcessaire.  Les  diagram mes  suivants 
lllustrent  la  mdthode. 


ita 


lure, 


: 


2X 


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A!Mn 

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IvOf^M 


DISEASES 


OF    TIIK 


KIDNEYS  Ai\J)  liLADDER: 


A  TEXTBOOK 


KOK 


STUDENTS  OF  :\IEDlCmE. 


HV 


'IcXlJTT,  M.I).  M.Jj.c.s.  Ka.  L.R.c.p.  Rd., 


'K.CUTVi      .:X.ACTINU     .S8,»r*VT     nH,...,N     t.     .. 
KAVV,    tTC. 


r  »  I  I,  A  I)  E  L  !•  H  I  A  : 

J.  B.   LIPPINX'OTT   COMPANY.  / 

1893.  Uil'^^^ 

(      OCT   15  1892  t<- 


\%^-.\ 


f- 


->  «l»BMlun,jj  ..iM-nw:mm,ja,m».'Km 


W?ff^1WJ"!WBi^ 


'^  -^ftT 


^0 


Col'VllIGllT.    \^'J2, 

nv 

J.    H.    liirrlNCdTT   CoMI'ANV. 


Printed  bv  J.  B.  Lipfincott  Cokpan*,  Phiuoiiphi*. 


IVUKFACK. 


T.'iis  hook  is  liasi'tl  ii|i(iii  iiutfs  of  li'cturt'H  dclivcrtd  to 
tln'  iiu'diciil  htiidcnts  of  tlic  I'liivcisitv  of  Ciilifoniiii. 

Some  of  till' li'ctiin's  Imvc  hccn  rcviscil  ;iiii|  clalioriiti'd, 
iiTid  dividi'd  into  cliaiitiTs. 

'I'll*'  iioiiifiicljifiiri'  of  kidiicv  diseases,  |iai-ticidarlv  of 
tlie  iiiMaiiiiiiatorv  varieties,  lias  heeii  sinipiitied  as  niucli 
as  iiossihle,  ill  tlie  hope  that  it  may  tlius  lie  tiie  more 
readily  understood  hy  the  student. 

The  illustrations  are  oritrinal.  and  tor  sonn-  of  the 
|iatho|otricaI  s|K'cimens  I  am  indehted  to  my  i-nnfrtri'H 
I'rofessors  ]{.  A.  Mi-Lean  and  1).  \\^  Montiroinery,  and  to 
Professors  J.  II.  Stallard  and  Louis  Mazet  of  the  I'ost- 
(Jraduate  Department. 

I  Inive  uIho  to  express  my  thanks  and  olilii-ation  to  Dr. 
Frances  M.  (ireeiie  for  the  int*'rest,  zeal,  and  intelliirenee 
she  exhihitccl  in  reporting  these  lectures,  and  for  assist- 
ance in  their  revision. 

104  Si'TTKit  .Stkekt,  San  Frantisco, 
September,  ISrrJ. 

lit. 


•  ' 


>j 


•  » 


CONTKNTS. 


SKCTION    I. 

I.     Ariiiloiiiy  ntid  I'hv«i(i|o;;v  of  the  Kidn.'vs  . 
II.— Afiutimli. .«.,(•  l'(,Mti..n,  Foiin,  iin.l  Niinihor 


PAdK 

7 


SUCTION    II. 

PIsKASKs   OK   TiiK    KlliNKVS. 

I. — NpphnilijiH 

II.— Uvpcni'iniu— CdimcstiDii  nf  tli.'  Kidiii'VH 

III.— Hiifiiiitiiriii  ' 

IV.— Kdil.'tiiic  HnuMiitiiiiu 

V.-H,,.m,.tinun,. -.S,.un,..i.-    or    Fnls,.    IIirmatum-H,,.,.!.,- 

i;loliiniiriii 

VI. — Anii'iiiiii 


VII 
V!!l 

IX 
X 

XI 
XII 


XIII. 


XIV. 

XV. 

XVI.. 

WII.. 

XVIII.- 

XIX.- 
XX.- 


;io 

41 


41 


—  DiMii-c- of  llic  Koiiul  lilood-Vfsscls 
-rriiH'      

--C'ii.Ht.H  of  ihi!  UiiiiifiToiH  Tiilmlcs 

— .Mhunnn 

-Ni'|>liriti-i -llri!,'|it'a  Disoiwc 

-Ti.lMilar  N.'i.liritH-Tu».nliti.s-Ti.lml  VridirilH-ln...^.,!,,,- 

iiiatlvo-  r„ta.Thal  -Croup,, us    ^  Aout.' -  Huliacutc - 

CliMnic 

-IntortulMilar  Nophritis-Infrstitial  Nopbritis-Granular 
Kidncy-(;ou»y  Kidn."y-ContraH,d  Kidn,.v-Cirr!.,.(ic 
Kidney    .    , 

-N'.j.hritis-Difrusp  No,)hritis— Nephritis  Vt.ra-I'ar..n<liv- 
nuitous  Ncnhrltis 

-Suppurntivi'  Kidney— Abscess— Surgical  Kidney     .    .  j,); 

-TuLereular  Ki.lney-Nepl,ro.plithi-i.s-Tul)er(uloH8.        .     kw 
— Uneniia 

-Degenerations-  Amyloid  Dp,i;<.nerution  —  Lurdacoous  .,r 
Wnxv  Kidnev  .        ... 


-1,") 

4i\ 
4S 
04 
(1« 
73 


ID- 
IOM 

11. t 


IL'O 


-Atrophy  and  nypertro)i)iy ,.,,, 

-Tuinur-  and  New  Growth.-s jitr 


J6e«fflSaS55«ESWlft5J«>sBS=!.5ar»r 


(•(>.\n:xTs. 


'1  • 


SKCTIUN    I  1  I 

msRAKKS    iiK    TIIK    I'KIA  IH. 

rllAKr>H  '*"" 

I.  -Ki-iml    Ciiloulu*,  St.iii..,    Stotiy   (•..niMinim— Ki'iiul    Cnhv— 

N.Hlin.-l,itlii«»i*— Pyi'liti"  I'lil'  iil.iMi— ("iili'iili  K<imliu  .    .  13S 

|I._l'j..liliH '■♦7 

III.— rv<).Nt.|.lir.>(.ii<(Nc|)liP'>-l'y'>«ii<— Pyl'i-Ni'l'lT"*!") '•*" 

1\'.      ||\.|r..-Ni>|.hr...i»  (llytlroim  Ui'iitiliH— Uy(lni-N('|)lirciiil  .    .    .  150 

V     -I'liiiP  jiliiilU         '''- 

VI.— rp't.Ti ''["i) 

VII.— Suit.'iriil  Ti"iitiii(>iit  111' till'  KiiliM-VH l'"'^ 

SKCTION    !  V. 

MSK.XHK.S    itV    TIIK    III.AI'I'K.U. 

1.  — Atiiitniny  of  till-  lilucMrr '|]|* 

II.   -('\-tiilKiii ']]" 

III  —  IlyixnisthiMii  (Iiritiiblc  Hlmlil'T) ^'J 

IV.— AniPHllH-Kiii  (Aloiiy) '""^ 

v.  — Cystospn^iims    (Vc>icHl     S|msiii -Spii>m    i.f    the    Itliuld'T - 
(■\.t(.-|,MMii— SpiiMiius      VtHira'— li-chiiriii     S|p|i«liii)ili<'ii— 

('y-to-|m.-titiis— IIypi'r<'iri<'>i>)  .     .        1*^' 

VI._C'\>t(>i.icLriii    (riirHlv>iH    ..(•  till'    Ulii(lil.T-Acin(«iii— VfMoil 

■I'iv)     .    .    .    .■ '^■■' 

VIT.—V.'sifiii  riil'iili  (Cy-to-Litliiii-i^l 1**^' 

Vlll.— t'y<l<.rilmf;iii   (Vi-i-ui    llniniitnria— Ilcmorrhmjn   t'nuii    ihc 

"lil.ul.l.r) '**" 

IX.— Cvstitis— Acuti',  Sulxuutc,  aiitlChmiiii' !>*« 

X. — Pcrioy>titis 

XI.— Ilyi.iTtmi.liy  (.f  lht>  nindiliT '''J' 

XII.--NVW  <ir.iwtiisHii(l  F.T(i._'ii  Hoilic's  in  till'  niaiKlcr 20|1 

XIlI.~Knim>is  NtKturna  (Nocturiiiil  IncontinenciM '-'l>i 

t 

SECTION    V. 

T. — Diulioto.s .'    '    '    '    " 

II.— Diiiln'lc- Mollitus  (MoUituria— (llyoosurin— (JlucosuriiO     .    .    211 

111.- Diiilii'ti'*  InMi.iiiii*'  I  Pi'lynna— Uso/.cniii— Ilyosuritt)  .    .    .    .    224 

IV.— Anazoturiii— ()lii,'iiria— Aisoturia 230 


I 


PAiiR 


.hr- 

— 

lii  . 

.     1.1.1 

147 

.    14!» 

,    150 

.    IW 

.    \r,.\ 

.  v,-> 

\w 

1       «       •       • 

17'J 

.    .    .    . 

174 

.    .    ■    • 

17H 

ulll'T  — 

iidifii — 

181 

■Vi'sii'iil 

»       .       .       ■ 

18H 

.       .        ■       ■ 

18f. 

nlU     tln' 

»      .      •      ' 

1H7 

18M 

•      •      •      • 

108 

.  .  .  . 

190 

.  .  .  . 

20;  1 

•      t      •      • 

ao7 

210 
211 
224 
230 


MST   OK   ILLUSTRATIONS. 


I. 


H. 
'.I 

U\ 

II. 

12. 

M. 
14. 

l.l. 

Ifi. 
17. 

18. 


V  1    1..  1  ''A'"! 

.N'lniiMi  Kiijni'v ., 

rni'il'.rdii- '^ihiilis  iiriil  .Mul|)ii;liiiiM  Tiil'ii* n 

iliiiM'fihoi.  Kiilmy .,(. 

riic  A<'i,l  <'rv>tiili     ...  '    '        % 

0( 

I    nitl'  ri|    S'mIIiiIII   ("rV'tlll.i ru 

•  Kaliiti' of  I.iiiK- ('rytiiU 50 

.\iiiiiiiiiiiiiiii  l'li(i-|ilmlis ,l(, 

'I'll 111!  t'nst.< ^,, 

I'M'iiih  s  Allmiiiiri  M.ti'P -,, 

I'us  Cori.iisclr.s  t'ri.>li,   I'lH  ('..r|)iiscl,.s  i.ltiT  tli.)  nctidii  of  Atvtic 

Aiiil      -.^, 

.Micrnsc(.pir  Scitic.n,  Tulmliir  Nt'iilirili.s nO 

IiitiiMitiiil  Ni|)liriti>,  — Oriiiniliir  Ki<liii'y {)(•, 

Miiriiscdjiic  .-crtioii,  Cliroiiic  IntiTtuliiiliir  Nephritis <)7 

Ml(rn.((i|iic  ■.(.(•ti.iii,  Nt.|,liritis  (ilitCuM') 104 

'riilx'tfular  ivi<Iiii'y j]() 

(\\-tic  I)i'i;i.in.iiiti(in  of  Kidiiuy ];(i 

Ni'plii-ii-litliiii.-is      |.jr 

l{flml  C'nl(.'UlU8 will 


1» 


■'wCT»Dg!paaM^SSg!a?Fg.w;wK:::.?>8Pfwm«»i'iM!i'.i'' ■»>«'•' 


-^J 


ii 


11 


!!• 


11 


i 


^  f-i— 


itaM 


-^J 


DISEx\SES 


Of   THE 


KIDNEYS  AND  BLADDER. 


SECTION    I. 


CTIAPTEIi   I. 

ANATOMY    AND    I'll YSIKI.OCY    UK    TIIK    KlUNKVS. 

TilKRK  iiiiiy  1h'  ortrans  in  tlu-  ImkIv  tlu'  fticiloiry  iuid 
patlioldiry  of"  wliosi'  (lisi-asi-s  \vc  may  iimK;rst!tinl  antl 
ju'rhaps  treat  iuti'llij^t'iitly  witlio.it  a  knowlodifo  of  their 
anatomy  and  |tliysiolo,i;y ;  but  the  kidneys  cannot  he  ehissed 
anionu:  them.  A  thorou<rh  knowledtre  of  tlie  normal  anat- 
omy, pliysioloiry,  and  liist(doiry  of  the  ki(hiey  is  indis- 
pensahh'  to  tile  |»roper  nnderstandinij  of  the  etiology  and 
sym])toms  of  its  patlioloijieal  conditions. 

The  tirst  tliiiiLr  to  realize  is  that  the  kidneys  are  <;landn- 
lar  orLTans,  sitnatcil  one  on  each  side  of  the  vertel)ral 
column,  behind  the  peritonoim  and  iK'twH'cn  tlie  ujnier 
border  of  tlie  twelfth  dorsal  and  tliird  lumbar  vertebnw. 
The  rii^lit  kidney,  by  reason  of  its  vicinity  to  the  liver,  is 
s]it,'htly  lower  than  the  left,  its  upper  border  beiti<;  on  u 


••■««-«iaerasisf'«i  aii»a9g^»teai!!MKSBga.Mtt«i»ni»»«M"«  i«-i<yiiii»»»i 


fi  i)isi:.i.si:s  or  riii:  i<ii>.\i:ys. 

lovcl  with  the  lower  iiinruin  <>t'  llif  rlrvrnlli  rili,  wliilc  tliat 
ot'tlir  left  siilc  Itcuiiis  ;it  t iu' iipitiT  iiiaru'iii  of  tlu' siiiiu'  ril>. 

Tlir  kidiH'Ns  iifc  aliiMit  I'niir  iiichrs  ill  Iciii^tli,  tVuiii  t\V(» 
to  iwip  ami  a  liali' iiiclu.-  in  Ipnailtli,  ami  rather  more  than 
ail  imh  in  thi.kmss.  'rhe\vei;:hl  ofthe  kidiieviii  tiie  iiiah- 
is  from  four  and  a  half  to  six  oiniees;  in  the  female  it  is 
somewhat  less. 

It  is  well  to  p'liiemlier  that  on  the  i-iirht  side  the  kidm  y 
is  in  relation  ahove  with  the  riiiht  lolie  of  the  li\er,  and 
Itelow  willi  the  deseeiidinir  portion  of  the  ihioileiium  and 
the  ii|)|u'r  part  ofthe  ase»'iidiii,u- t'oloii  :  on  the  left  side,  with 
the  under  siirtluv  of  the  stoinaelu  the  extremity  of  tho 
liam-reas,  and  the  deseendiiii;-  colon. 

In  exaiiiininn-  the  kidney  for  eiilaru'eineiits,  ttimors,  etc., 
alwavs  place  the  |iatieiit  in  the  dorsal  posilion  and  use  tlu' 
himanmil  method.— one  hand  i.eini;'  under  the  patient  on 
the  Imiihar  re^'ioii  lietwecn  the  lowi'f  rih  and  the  cnst 
of  the  ilium,  tlu'  other  on  the  alidoinen  directly  over  the 

kidney. 

A  few  spasmodic  efiorls  of  the  haiul  on  the  alidoiueii 
will  fail  of  rcsiilt>.  I5iit  with  the  patient's  knees  drawn 
up  and  pressure  made  steadily  witli  the  upi>er  hand  durin.i;- 
expiration,  kecpinu-  it  liriii  and  inactive  diiriny-  inspira- 
tion and  continiiiuii-  the  p.-i'ssurc  duriiiir  the  next  few 
exjuratioiis,  you  will  tind  that  in  a  few  minutes  the  kidney 
will  l>e  lictwi'cn  your  liands,  ami  you  can  ted  its  si/.e  and 
shape.  This,  of  course,  cannot  he  easily  accomplished  in 
corpulent  persons,  .lerky  movements  will  cause  failure  in 
U)iv  case.  On  percussion  you  will  tind  diiliiess  hi'twei'U 
the  twelfth  Hit  and  the  crest  of  the  ilium,  and  you  must 
judiii'  ofthe  size  ofthe  or<raii  hy  the  area  of  the  dulness  : 
ite  careful,  however,  not  to  confound  it  with  liver-duluess, 
as  iHTcussion  doi's  not  always  yield  a  very  e.xact  kuowl- 
odire  of  the  size  of  the  kidneys.     Do  not  forget  thut  they 


•  •jm'iT'rBnn'Dmtr' 


.I.V.I /'".u J'  .iM>  riiyxioi.Dtiv. 


9 


lie    l.t'liiiid    till'    pt  riti.iu'iiiii,  iiiiil   tliut    the    ri^lit   k'ulncv 
iimvi's  witli  rfs|iir;itit>n. 

Si»  t'iir  as  till-  'lisciiscs  of  the  kidney  iirc  idiicfnu'd,  it  is 
lu'ci'ssafv  I'ltr  tlic  |>ii_v.-ifi:m  to  iH'iiu'iiilKr  that   tlir  kidney 


Kki.  1. 


Capsule 

Pyramid 
Calyx 


.Cortical  Portion. 


consists  of  throe  distinct  tissues, — viz..  nrinifiTons  tnhnh'S, 
l)l(.od-vcsst'ls  with  their  Mal|»i,i!:hian  tnfts,  and  the  iiiter- 
tuhular  sti-nctnre,  i^eiierally  called  tihrous  interstitial  tissue. 
Wo  divi'lc  the  kidney  into  two  i»rinci|»ul  portions,  the  cor- 
tical and  the  niedullarv.     The  inediilhiry  portion  is  sulxli- 


■"'ftl».JW    l-l 


.r^r 


111 


jusKAshs  nr  rtir.  KinsEvs 


vidi'd  into  i.,vraiMi<ls.  ( i.iii|M)siil  tui- the  iiio>t  imrt  nl'.-t'';ntrlit 

rullctillU'-tulK'S.  wllosr    hilMS    VvM    oil    fll<'   corlif;!!   l.ii!'li(>U 

ami  uliusi'  !i[iii''  "oiivfi'irf  lov^aid  tlic  cciitrr,  wlicif  lIu'V 
f.irii'  llii-  papillii  wliirli  itrojt'ft  into  tin'  caliri's  or  i'X|iaii- 
■<i.iiis  oftlu'  iirfliT.  TIh' cortical  iiortioii  i-*  iiiofc  vascular 
than  the  iiuilullary,  and  contains  the  greater  nunil.cr  of 
Malpiirhiin  hodics,  sn)all  roundi-il  masses  a\cra;-in,!:' al'out 
on*  onc-hiin»lrc(l-aii(l-t\vciiticlh  ot"  an  inch  in  diameter. 

Kach   of  these   little  hodii's  i>  eonilposed   (d'  two  pari-,  a 
central  i:'loinernliis  of  vessels,  calle.l  a  Maliii-'hian  tull.  and 
a  niendii-anous  eapsule,  or  cai.sule  of  Hownian.  which  is 
the  eoninicnccHient  of  a  iiriniferous  tnlmle.     Tiiese  Nhil- 
piirhiaii  tufts  are  made  up  of  a  net-work  of  capillars  hlood- 
vessi'ls    held    toiri'lher    hy    scanty   i-onnective    tissue    and 
dt'rived    from   a   small   arterial   twiir,  the    afferent    vessel, 
which,  with  the  roultini;  vein,  tlie  efferent  vessel,  pierces 
the  capsule  at  a  jioiut  opposite  that  at  which  it  is  eoniK'cti'd 
with  the  tuhe.     Tlu'  capsule  which  siirrounds  the    ;loii,cr- 
iilus  is  composed  of  hyaline  memlirane  (•(•ntainiii:;    i  >nuill 
amount  of  fim-  connective-  tissue'  which  is  continuoii    with 
that  of  the  tul>e  and  is  also  reflected  over  the  caj.illar.s  net- 
work and  covereil  l)y  st|Uamous  epitiielium.     Thus  a  cavity 
is  formed  hi'twet'U  the  capsule  and  the  ,i;l"inerulus,  which 
variivA  in  sizi-  accordiu-r  to  the  state  of  secretion  and  the 
amount   (.f  fluid   present  in   it.      The  urinifen.us  tul.ules 
commence  at   flu-  constriction  or  neck  of  the  capsuU',  and 
heeome  convoluted  while  iMirsuinu:  a  considerahle  course 
in  the  cortical   portion,  where  they  are  ti'rmed  the  i>rn.f- 
Imal  roin-uhifnl  tiih'ihs.     The  convolutions  then  disappear, 
and    the   tuhules,   now   ti^rmed    the   /'//'"/<>•  ';/'  Srh,irln„ni, 
approach  the  nieilullary  portion  of  the  kidm-y  in  a  more 
or  less  spiral  maniu'r.      As  they  I'uter  the  medullary  por 
tion,  the  tuhules  suthleidy  heeome  much  smaller,  straiirht 
in  direction,  and,  dippinu;  «lown   for  variahlo   depths   in 


ASATOM)-   A.\l>    l-nVSHtWdV. 


11 


iil'sfiMirlit 

;ll   ]Mi!'ti('il 
liclf  lIli'V 

or  fX|iim- 
(■  viisculiir 
iiiiiilpif  lit' 
riiiu;  iil'iiut 

illluttT. 

^■(t  |i;irts,  a 
11  tiil't.  and 
I.  which  is 
'lu's..  M'll- 
larv  hhiixl- 
li-siif  aii<l 
rlU  vessel, 
<cl,  |iirrees 

collllcrti'd 
he  :liilhiT- 
II-  I  >iiiall 
luoi.  \y\t\\ 
|(ilhir_\  iit't- 
iiis  a  cavity 
ihis.  which 
>ii  ami  the 
Ills  Iiiliiilfs 
[ilisulc,  and 
I  hie  cdiirse 
1   tiu'  in-nx- 

(lisaippcar, 

Si'hdrliiiiru, 

\,-  in  a  nioi'o 
lullarv  ]iiir 
IT,  straiirht 
(h'jiths   in 


the  ityraniids,  eoiistitiiti-  the  deseeiidin.i;  linih  of  a  curve 
known  as  llenU-'s  loop;  eiilar.t-in.ir  as  they  reasci-id  to  tlie 
corti.al  poftion,  they  hecoine  apiin  spiral  in  din'etion, 
t'oniiiiiLf  the  asiviidiiii;  liniii  of  Ileiile's  loop.      After  eiiter- 


1,  ViilplKliiftii  tiilt;  2,  cpltliclium  liiiiiiK'  linwinan's  cnpsiile; 
n,  I'liilhclial  (MivcriiiK-.  1.  •■imvolutod  luhes  of  Cdrticul  pmtiini; 
5,  Ui'iile'sloDp;  i>,  <'()lk'ctlii«  tubes. 

iuff  the  cortical  portion  narrower  and  irre.iriilar  in  outline, 
they  once  more  dilate,  heeoine  convoluted,  foiininir  the 
distal, '<n}r„hih<l  tiih,\  and  with  a  final  heiid  enter  the  strai,<;ht 
collectin.ij  tiil.es,  which  continue  downward  throu.t?h  the 
medullary  nubstatice  to  open  at  the  apices  of  the  pyramids, 


12 


hisK.isKs  OF  Tiir:  KH>.\j:is. 


1  ( 


iicfiiiu;  siiiinly  us  ducts  lliroiiyli  wliidi  tin-  nriin'  funis  its 
wiiv  into  tlic  pi'lvis  uf  tlu'  kidiicv  iiiid  iirctt'i'. 

Tlu'si'  colU'ctiiii;  tidmlcs,  coiiiiiu'iiciiii^  l»_v  iiiiiiiiti'  o|icii- 
iiiirs  ;if  tlic  n|iiccs  of  tlif  iiii|iillii'  jiiid  cxti'iidiiii;'  iiitii  the 
kidiicv,  dividiui,^  diclKitoiiioiisly,  lonii  tlio  _ijroiitiT  pait  <it" 
llu'  |>_vriiiuids  (tf  tlic  iiicdulliiry  sultstaiicc.  In  the  cdi'ticid 
|((M'ticiii  tlicv  arc  arraiiijcd  in  conical  ,ii'r(tii|is. called  iiii'did- 
laiT  ravs,  of  [ivraniids  dl'  Fcrrcin,  and  rcci'i\ c  on  cadi  side 
the  curved  extri'initics  of  the  convolutt'd  tuhules. 

J'J/iif/u/iiiiii. — The  e|)ithclial  lininii' of  the  tuhnli  urinifcri 
ditlcps  in  its  character  in  the  various  parts  of  the  tuhes. 
Till'  ca|isiiU'  and  neck  are  lined  with  Hat  cells  contain'ini^ 
an  oval  nucleus.  In  the  proximal  convoluted  tuhes,  tho 
spiral  tulii's  of  Schachowa,  and  the  distal  convoluted  tuhes, 
tlu-  epithelium  is  |iol\-|u'dral  in  shape.  These  cells  are 
made  lip  of  more  or  less  rod-like  tihres,  one  of  whose  ex- 
tremities rests  upon  the  basomont  memhrane,  the  other 
pn  tiiii,'  into  the  lumen  of  tlio  tube,  ^ivinu;  the  cells  a 
flistinctlv  striated  appearance.  In  the  desccndin<i'  limb 
of  Jlciile  the  ei>itlielii.m  resembles  that  which  lines  the 
eajisule  an<l  luck,  while  in  the  asceiidinir  limb  it  a.u'ain 
beeomi'S  polyhedral  in  shape.  The  cells  liniiii;  the 
irreg'ular  tubes  are  very  angular,  with  more  prominent 
striations  and  rod-like  markinii's  than  any  otlu-r  jiortion 
of  the  tubules.  The  t'pithelium  of  the  strai_u;ht  tubes  be- 
eonu's  more  or  less  columnar,  this  tendency  inereasinjjf 
toward  the  jiapillary  portion,  where  it  is  distinctly  colum- 
nar and  transparent.  This  arraiii^enu-nt  must  havi"  some 
design.  Charcot  says  he  believes  that  the  epithelial  cells 
are  the  real  seeretiui;  portion  of  the  organ,  all  tlu;  urine 
that  is  not  iiltered  through  in  tlie  capsule  being  secreted 
here.  The  constrictions  in  parts  of  tlie  tubules  would 
sei'in  to  be  for  the  purpose  of  arresting  the  too  rapid 
onward  flow  of  the  urine  until  the  eiiithelial  cells  have 


.ty.lTiiM)    .I.V/)    I'liysln/.ntii: 


18 


\v  finds  its 

illlltf  oprll- 

wjj;  iiitii  llio 
III  r  parf  of 
tlic  ('(H'tical 
It'll  iiii'diil- 
11  I'iicli  sido 

ili  iirinifrri 

tlu'    tlllll'S. 

coiitirniiiiuf 

tulti's,  tho 

utc'd  tiilics, 

('  (U'lls  arc 

whoso  I'x- 

,  the  other 

tlic  colls  a 

idiiiii'  liiiib 

1  linos  the 

1)  it  a<jain 

lininif   tho 

proiniiiont 

UT  portion 

t   tllllOS  l»o- 

iiu'ri'asin<ij 
•tly  ooluni- 
liavo  some 
liilial  oolls 
I  tin;  urine 
i<^  secreted 
des  would 
too  rapid 
cells  have 


pcrroriiii'd   tlu'ir  otlico  ami  addod  t.i  tlio  walfi'v  portion 
of  the  urine  its  solid  iiii^roilionts. 

It  is  vorv  ii.'cossarv  tor  voii  to  roiiH'inlior  tlic  principal 
toatiiros  of  the  oirciilation.     Tlu' first  thin,:::  loalliari  voiir 
attention  is  the  fact  tlii't  tho  roiial  artorv  is  tho  larirost,  in 
])rop(irtion  to  tho  si/o  of  tlu'  ortraii  siippliod,  nfanv  artery 
ill  the  liudy.      It  may  sooni  stramj:^-  that  it  is  tho  larn'ost,  not 
only  ill  that  rospoct,  hut   also  in   proportion   to  the  ronul 
vein.     When  wo  ooiisidor,  liow»'vor,  that  in  olhor  orn-ans 
uhoiit  the  same  amount  of  hlood  is  rotnriiod  iiy  liio  veins 
us  enters  the  origans  throiiirh  tlu'  artorios,  while  in   the 
kidney  a  (piart  or  two  of  tliiid  is  filtered  throiiiih  tho  cor- 
jtuselos  each  day,  wo  shall  see  tho  necessity  for  its  veins 
hoiiiir  of  smalh-r  oalihro  than  its  arteries.     The  renal  aiterv 
on  oiiteriiiir  the  jwlvis  of  the  kidney  divides  into  sowral 
hraiichos,  hoarini;  the  naiiio  of  artoriu'  propriie  renales, 
which,  aftiT  travorsini;  tho  oolinnns  of  iJortitii,  supplyini; 
in  part  the  pyramids  of  the  nu'dnlla  and  atioreiit  vt'ssols  to 
tho  Malpii^hian  hodies  in  that  ri'irioii.  divide  at  the  liaso 
of  the  pyramids  into  two  sots  of  hranchis  for  the  further 
supi>ly  of  tho  or^^m, — viz.,  tlie  interlohular  artoriis  and 
the    Jirteriohe    roctie.       The    interlobular    arteries    pass 
directly  outward  hetwoen  tho  pyramids  of  Foiiein  and 
ti'rminate  in  the  capillary  not-work  of  the  oa]isiile.     From 
these    arteries    are    derived    the    afferent    vessels   of    the 
Ijlomeruli  of  the  cortical  portion.       The  artoriohe  rocta> 
supply  the    medullary   pyramids,  whose    substance    they 
traverse,  terminating  at  their  apices. 

The  veins,  as  we  see,  are  derived  from  the  three  arterial 
divisions.  Those  i)enoath  the  capsule  are  stellate  in 
arranijomont,  pass  downward,  rocoivint;  branches  from  the 
plexuses  about  tho  tnladi  contorti,  and  at  the  bases  of  the 
Malpiirhian  pyramids  join  the  vena'  recta',  which  are 
derived  from  the  plexuses  at  the  apices  of  the  pyramids 

2 


'iaiMUai'nJi-miet»nf<'m..f  ^ai 


14 


iHsiiAsKs  <*/••  rill-:  A7/>.\7;)-v. 


iiiid  t'iKiii  till'  [.rnpiT  ri'iiiil  vtiiis.  'I'lif  viiiM'  |M«t|iri!i' 
rciiiilis  iiiiM>iii|)iiiiv  tin-  artcriii-  |iri>|i'Mii'  ri'iiiilts  Itctwtcii 
tlif  iivnmiitlH,  ri'ccivinjx  iti  their  coiirsf  tlic  tflt  icnt  vrsstls 
iVinii  till'  trluiiu'i'iili,  im«l  ill  tlif  sinus  of  tin-  kidiny  juiii 
witli  till'  veins  lioin  ntlier  |>_\  ratniils  to  t'orin  llie  reiiiil  vein, 
whose  nitiniiite  (hstiiiiitioii  is  the  inferior  vena  eiiva. 

All  the  iirteiies  iiinl  veins  interhiee  ami  eoMi|ihtely  sm- 
roiilitl  ll'e  tiliiMJes. 

It  is  well  to  iu'ar  tlie  foreiroinir  iiiets  in  iiiind.  as  we 
rtliall  see  wlieii  Wi-  eonie  to  tlie  suiijeel  of  li y|>era'iiiia  lliat 
tho  rosistaiiee  elleonntereil  liy  tile  hlooil  wiiieli  passes 
thronifli  tlie  irlonientli  is  fiir  jjri'ati'r  than  that  met  li\  the 
vessels  that  tiow  direetly  into  the  eapillaries,  ;nnl  heiK'e, 
when  the  ltloo(l-i>ri'ssni'e  is  raisetl  to  any  tleirree  from  the 
lieurt's  aetion,  tlu'  hypenemia  will  he  eoiiiimMJ  to  those 
portions  of  the  kidney  wliere  the  hlood  mei'ts  the  trreatest 
rosistanee.  which  are,  of  eoiirse,  tin-  i^loineriili  and  the 
eortex.  This  explains  the  inereased  seeretion  of  urine 
tVoni  heart-pressure.  We  shall  see,  on  the  other  hand, 
that  when  the  hypenvMiiia  is  tlii'  result  of  venous  ohstrue- 
tioii,  the  ensfor^ifeinent  is  eontiiied  to  the  vi'iiis  and 
capillaries  and  cannot  extend  throiiuh  the  narrow  etVereiit 
vessels  into  tlii'  j^lomeruli.  Vou  will  then  understand  the 
natural  ri'sults  of  such  conditions. 

Thotihrous  intertnhular  or  interstitial  tissue  is  not  very 
ahundant.  In  the  cortical  jiortioii  the  tuhi's  are  not  sui'- 
ronnded  hy  much  Hhrous  tissue;  hut  I  desire  to  impress 
upon  your  mind  the  fact  that  the  I'apsules  are  completely 
enveloped  in  this  lihrous  tissue,  and  that  the  capillaries  of 
the  irU)ineruli  are  covered  with  a  tine,  delicate  connective 
tissue,  whicli  also  lines  the  capsules.  This  will  he  recalled 
to  you  when  we  take  up  the  patliolo^ry  of  «;outy  kidney. 

The  kidney  is  plentifully  supplied  with  nerves  from  the 
solar  plexus,  the  semilunar  ganglion,  and  the  splanchnic 


=!;viniSl:-J«,.sw.;y-=  >»a»Wi.^y!«w»ili»*lM«»»«»v.f».i,aW«aWH54S«BC>^^ 


.i.v.ivou)   .i.v/)  i'insii)/,t,i,y. 


16 


lur    |tl(i|inil' 

U'A    llctWt'Cll 

•r»'iit  vi'sst'U 
kidiH'v  jiiiii 

•    I'tlKll   Vtill, 

I  cava, 
»|»lctt'l,v  Hiir- 

iiiiiiil.  as  we 
ci'a'Uiia  llial 
liicli  passes 
iiift  liy  tin- 
,  ami  lifiK'f, 
vvr  t'roiii  till' 
n'd  to  those 
the  iTl'rati'st 
'iili  and  the 
on  of  urine 
otliiT  lianti, 

KtUS  ()l>stlMU'- 

viins  and 
TOW  ctK'rcnt 
dcrstand  the 

f  is  not  very 
art.'  not  s\n'- 
e  to  iniprosH 
e  conijiU'toly 
•ai»illaries  of 
0  contu'i'tivc 

II  1)0  recalled 
ity  kidney, 
■ves  from  the 
e  sphinchnic 


nerves.  Thest-  coni|iletely  siirronnd  the  tnladcs  and 
Mood-vessels, — a  dis|io>ition  '.vhich  explains  how  it  is  that 
sniull  iid'arcfioiis  or  tri'i'vel  may  iri\c  rise  to  the  exi|iiisitt' 
|iain  which  they  occasion.  They  also  coniniiirdcate  with 
the  s|ierniatie  plexns,  whence  the  sympathy  existin.};  Iie- 
tween  the  kidneys  and  the  testicles. 

A  \\i>rd  aliont  the  nrine  itself.  We  know  that  it  is 
made  lip  lari;ily  of  water  holdinu'  in  snspension  orifiinit! 
and  inoriranic  salts,  the  most  important  ot'  the  toiiiu-r 
heinu-two  sidisfaiices  rich  in  nitroijcn, — vi/,.,  una  ami  nric 
mid.  In  other  words,  it  holds  in  suspension  the  salts 
which  are  the  result  of  tissuc-nietaniorphosis.  Tlie  skin, 
liver,  and  howels  do  their  part  in  elimination,  as  must 
also  the  kidney.  The  (piestion  now  is.  What  part  of  the 
kidney  secretes  the  nrine  ?  There  is  no  lomjer  any  douht 
hal  the  Malpii^hiaii  tuft  is  the  part  where  nn»st  of  the 
watery  portion  of  the  urine  is  separated  from  the  hlood  ; 
and  it  is  prohahly  almost  a  mere  filtration.  Lndwiii'  and 
others  ti'll  us  that  the  uriiu'  is  entirely  the  result  of  fdtra- 
tion,  and  hence  is  an  excretion.  This  is  an  error:  if  the 
tuft  excretes  the  watery  portion  and  the  s.ilts  also,  for  what 
purpose  were  the  intricate  and  delicate  tuhules  with  their 
ei)ithelial  linini;  a<lded  ?  The  short  straii^ht  tuhes  woidd 
have  heen  sufHcient. 

As  it  is,  the  watery  portion  must  follow  tlie  course  of 
the  tul)\des,  hein^'  retained  in  the  constricted  portions  and 
in  close  contact  with  tlu'  epithelial  linimrand  its  secretiiii; 
cells.  It  is  hero  that  most  of  the  salts  are  received  and 
secreted  hy  the  e]tithelium.  The  filtration  is  a  purely 
physical  procoas,  while  the  secretion  of  salts  in  the  tubules 
is  a  vital  one. 

.Some  authors  contend  that  even  the  watery  portioji  is 
not  a  filtration,  hecanse  of  the  fact  that  the  epithelium 
lining  the  cuiisules  is  reHeeted  on  the  tuft.     It  is  a  thin 


■I 


'^!i 


■') 


i^n 


1 


U 


nisH.tsHs  t,r  Tin:  hii>.\h:ys. 


">"'••'""  '"^  ""■••"■     lfifs..rv..  , th.r  |.,r,.u,.,  i,  ,.„,. 

Iiiip-  iv^iilat...  tl...   liltiiiliuM.  iiMTniHiiiir  or  IrsHrniiiL^  f|„. 

<l"''"tltV.    MS    ,1...    ,,,M..    ,„„v    1....  It     hi.s    >,.lM..tl.i„.,.    fo    ,|„ 

Willi   tlir   liltriiiiun,  mi.l   luiiv   li;.vr   iini.l,   i,.  ,1.,  uid,   (|„. 
I'Xfrrcii.in  ot'iilliiMiii'ii. 

S-'in..  uril,,.  s.lt.  i;.iiii.l  in  tl.r  iiii,,,.  i,,v  Iniiinl   in  .n.i.ll 

';''"l""""""'  "'"  ' •      '»'tl,......„.vnMn.l,„i..  „..i,|a,v 

'■"■  """"'    ""l""-'">it.      Ili,,|,„rir  :,..i,|  n.Ml   .•.vntin  .-uv  n... 
loiiriil  Ml  tlic  Ii|(i,m|. 

WlM.tl,..ri,||ll...  lUTMrnul  .iri.'M..i,lissin.|.lv.li,ni.,Mt..,| 
'■'""  ""•   '•' '  '"^  '^"'•t'-  <••■  "li.lh.r  |,Mrt  ..f  it  is  s,.,.n.j...| 

I'.V     til.'     .IMflHlilMl.     linin-     tllC     tlllMlIrS,     is     iu.     llM.hTi.1,.,1 

'|"''stM.n;    l.iit    111..   |.i'..l.i,|,ilifi..sMr..  lliiif    tlM-|„l.,.|..s   |,|av 

i;"   Mi.|.Mrrnnt   part  in  thrii-  sc.ivti Immmiis..  nilnr  salts 

'""""•'    '"    ''"'  "••'"'•  '"••'   i'«'t   ImiiikI   in  ll...  I.Iu.mI   as   sn.^li, 
an. I  i.iiist  l.c  Kcrivti-.l  I'.vtli..  r|,itli..|iiMn  ..r  til.,  till. 111.  s. 


rilAI'TKl{    f  r. 

ANOMAMKS    OI-    I'.isiTDN,    K..lt.\|,     \m,    :..  mhku. 

TllK  ki.IiH'Vs,  liki"  ..til..,-  ..rirans.  aiv  si,l,j,.,.t  f,,  crrtinn 
(Ic'viutinns  Irotn  tlfir  natural  |..,siti..n,  f;,nn,  an.l  „„nil.,.r. 
Most  ot  thcs..  ari'  (•..n,ir..nital  ;  ..tju-rs  an-  M..,|iii|....|  lati-r 
I'l  IK.-.  tlm.u.iTl,  a.vi.L.nt  ..r  .lis.-asc.  S..in..  ..f  (1,,.^  arc 
ai.|.r,...ial.|,.  .Inrinir  lit'.',  an.l  may  sinmlat..  \vi.K.|v  (lifi;.r..nt 
|.atlh.l..iri..al  ...n.liti.Mis,  .•l,all..n.ri„.  tl...  .an  ri.l'  atl..nti,.n 
ot  both  |.l..vsi,.ian  an.l  siirirn.n,  a  corn'..!  .liaimosis  i„  tho 
»nai..nty  ..f  instances  Loin-r  very  dilH.ult  an.l  in  s-nu-  oihos 
iiupossiM. , 

Mon.  froquontly,  hcwevi-r,  thcsf  an..,nali..s  ,,ro.ln,-o 
littl.-  .,r  no  inc.nvcnionw,  the  ronal  nin.-ti..ns  iKJn.r  satin- 
tuc'torily  perlortiied.  " 


!!    f 


■-*iiw<  j^jij-iiBji-^jwyiMi  viR'Vtfi*. 


A.MtM.t/JKS  ■>/•   I'ltsirms. 


17 


|iMi|M.,,.,  it  pcr- 
'  li^-^tiiiriif  till- 

lM(t|ii|,._r  (,,  ,1,, 
"    'In    U  itil     llic 

t'uiiiiil  ill  siiiiill 
<l  mil'  ill-id  life 
I'l'i'iitiii  iii'i'  iiui 

I'lv  tliiniii:,t(.(| 
I'  it  is  s.rictcd 

ill)     lll|i|i'ri(|)'(| 

«•  fiiliiilcs  play 

l.-^f    otlltT    KilltS 

•IoikI  as  Milch, 
ln'  IiiImiIcs. 


'MIIKR, 

'ct  f(i  certain 
and  miiiilicr. 
<'||iiii'cd  lafcr 
of  lliciii  arc 
•  li'ly  diifcrcnt 
'I'ld  attciitiiin 
lirnosis  ill  tlic 
in  sdiiii'  cases 

lies    ))r(KlMce 
s  bfiny  i^atin- 


A  '  oiiiliiiiatioii  III'  several  nl'  tlieiii  iii>v  occasiniiallv  lie 
|ire,eiii  ill  flic  same  siiliject  witliuiif  ;ri\iiiir  pi^,.  f,,  any 
diHfiirlmucc  whicli  mii-lit  ..ad  I.,  tlcir  detection  diiriti'ir 

liCc. 

I      ANOMAMKS    OK    IMSI'lloN 

Mis|,la.'eiiiciits  .»»■  flic  kidney  arc  iisiially  ilividcd  into 
llircc  varieties,  Hxed,  inovaldc.  and  tloafin;;',  acc(irdiii<r  as 
the  iiiis|ilaced  ofiraii  reinaiiH  perniaiiciit  in  its  al>niiniial 
I'n>iti.>n.  moves  in  the  refr(..|Mrituncal  space  with  more  or 
li'ss  rreedoiii,  or  lloats  in  the  ahdoininal  cavity. 

Fixed  niiil|iositioiis  of  the  kidney  are  mostly  coiiifcnital, 
the  ortrani^  also  lieimr  lre(|iieiitly  aliiiornial  in  size  and 
Hliape,  whih',  as  a  rnle,  they  arc  normal  in  stnictiire. 

When  ac(|iiircd,  the  imd|iositinn  is  often  the  result  of 
tumors  flrair.u'ini;  or  |»iisliiiiir  the  kidney  out  of  its  normal 
position,  \vhcii  it  hccomcs  lixcd  hy  iiiHammafory  acii(.n. 

Thu  arranircmcnt  of  the  renal  vessels  and  ureters  often 
deviates  more  or  less  from  the  normal;  and  malposition 
of  some  |>ortion  of  the  lari;c  intestim-  and  pcritoncMiii  is 
not  an  nmisnal  complication. 

The  siipra-rciial  capsiih-  rarely  acc(.mpanies  the  mis- 
phiced  kidney,  hut  occupies  its  usual  position.  Some 
writi'is  assirt  that  this  is  invariahly  the  case;  hut  in  three 
cases  out  of  eiirht  ol.served  hy  |)r.  David  Xewmaii  the 
lapsiilc  was  found  misplaced  with  the  kidney;  and  in  up- 
ward displacements  it  is  found,  accordinif  t(»  Cruvcilhier, 
on  the  inner  side  of  the  kidney. 

The  ahnormal  positions  in  which  the  kidney  is  liahlc  to 
!'<•  tixed  are  numerous.  It  may  he  fixed  in  front  of  the 
vtrteitrii',  on  the  hrim  of  the  pelvis,  or  within  that  cavity, 
where  it  may  he  tcit  either  throuirh  the  ahdomimil  wall 
of  throuirh  the  vagina  and  he  mistaken  for  a  tumor. 
When  so  situated,  it  is  liahle  seriously  to  emharru.ss  and 
eomplieato  iiarturition. 

b  8* 


I« 


;»/.s7,M.v/;.s'  "/•  77//;  A7/»  v/;j-.v. 


Til"  iiKi^f  rr((|ii(rif  itiiiir,.|iiiji|  iiiiil|ii)>.iiiiiii  is  tliiit  in 
wliirli  til.'  kiiliicy  Im  t'oiiiiij  Iviii;;  nlili(|iii'lv  on  tlir  fiiicni- 
iliiic  svii(lniiii|r(.«iM.  It  litis  iiIsM  licfii  t'niiiiil  >iliiiittt|  In-. 
hi<l''  fill'  iifcni-*,  Iviii.if  tiitiis\risflv  iMiwtcii  tlu'  n'ctiiin  uinl 
tli(   lil;ii|ilir.  or  inrosH  tin'  |iri>iiiimiii'<'  nf  tlif  Hiicrtiin, 

'I'lic  ii'ii.il  iiiiiiv  ill  tlifsc  casi's  iiMiially  arisrs  fium  uiif 
of  tlu'  ilims,  iir  I'ikm  llic  ufiita  iniiicdiatrlv  iiliuvf  jtH 
liiriiriiitinii.  Ill  a  rase  ri|i'iit(  (I  Itv  Mr.  hiirliani.'  in 
vvliidi  tlic  left  Ixiiliicy  was  ruiiiKJ  over  flic  sai  in-iliac  svii- 
(•liiiiidrnHiH,  tlitrc  were  llircf  arfcrifs,  tlic  princiiial  one 
lifini;  a  liramli  of  the  aorta  arisinir  Just  above  itH  liili.rra- 
tion,  aiiotlicr  arisiii</  t'loiii  tin-  riiiiiiiion  iliac  n{'  tlic  o|i|'0- 
nilc  ^i(lc,  and  a  I'.ird  Iroiii  the  inter. lal  iliac  ..1'  tlic  miiiii' 
Hide,  eacli  wii|i|i|yinir  diHerent  parts  of  the  origan. 

Occasionally  the  lolmlatcd  a|i|icaraiice  of  the  f.ctal  kid- 
ney is  preserved,  sii<f<;estinc;  an  arrcs^  of  development  in 
••ally  fdtal  lite.  In  a  case  recorded  l»y  Mr.  Canton, Mlie 
left  kiiliu'y,  loliiilatcd  an<l  of  a  rudely  o\al  shape,  was 
situated  helow  the  liifiiication  of  the  aorta  and  hctween 
the  eoiiiiiioii  iliac  arteries.  Its  pelvis  was  directed  foi  \var<l 
and  dilated,  owiii'.r  to  the  iinpactioii  in  the  upper  pari  of 
the  ureter  of  an  oxalate  of  lini*'  calcnliis  wciifhiii!;  two  and 
a  half  draehins.  The  patient  died  of  hroiichitis  at  the  n<r*> 
of  twciity-seveii.  There  had  hccii  no  renal  syniptonm 
diirini;  life. 

<'oiic'cnital  lixeij  misplaceiiients  affect  hy  prcfert'iicc  the 
left  kiiliiey.  In  twenty-one  eases  eolli-etcd  hy  Uoherts, 
tifteeii  occurred  in  the  left  kidney  and  six  i-  tlicrii^ht; 
in  every  instance  the  ahimrrnality  was  connned  to  one 
kidney.  Of  forty-four  cases  co!lccte<l  hy  Weishach,  thirtv- 
five  occiine<l  in  the  left,  ei;,dit  in  the  ri;;^lit,  and  one  iti 


»  Ouy'g  H.)sp.  Rep.,  IWiO. 

•  Putholojrifal  TningiictionH,  vol.  xiii. 


A.\OM.tt,IHS  OF  I'usirin.W 


i:i 


Mil    ]■*   lliat    ill 

nil    llir  HlltTU- 
I    Hillliltill    lie- 

li«'  rt'cliiiii  mill 

;'  HIHTlllll. 
r'lHfS   I'iflMl    ulU' 

fly  iilmvc  itH 
hiirliiiiii.'  ill 
n  tn-ilinc  syii- 
|iriiici|)al  one- 
vo  itH  bill  rcii- 
■  (tf  till-  ()|i|(i. 

•   (if    till'    Mlllll' 

•^niii. 

till-  t'uiiil  l<;.|- 
■vt'lu|iiii('iit  ill 
.  {'iiiitdii/  till' 
il  sliiijic,  was 
ami  iutuitii 
(•(•ted  forward 
ii|i|Mr  part  of 
fliiii:;  two  and 
ilis  at  till'  aiyo 
lal    s_viii|itoinrt 

ifiH  rt-iicc  tin? 
I  liv  liolfcrts, 
i-    the  rii^'lit ; 

II. lied    to    oiiu 

isiiacli.  tliirty- 
,  and  ono  ia 


Im.iIi  kidncvi*.  Ah  niranlH  hcx,  nii'ii  ncfiii  niorc  prrdi*. 
|>H»rd  tliaii  woin.ii :  of  I wrnty-niiit'  caHcs,  twenty  wtif  in 
linn  and  nine  in  wonnn.' 

.\<i|iiiird  tixi'd  nial|io.«ition  of  tli.'  kitlin'v  ociimm  ih  ilif 
n-iilt  of  roiitinin-d  |irt'sr*iirc  iijion  the  otiran  citlicr  l»y  a 
fiiinor  t'rowini;  in  the  vicinity  or  liy  an  inlaiircd  liver, 
'lilttii.  itancrcus.  or  sii|ira-rinal  liody.  jr  \i\i<  .■  aUo  lii>  the 
roiilt  of  liirlit  laciiiir;  or  the  kidiny  may  lie  <ii  lo.add  l»v 
a  siidtlrii  jar  or  lilow  .  and  iM.nnd  down  in  it-  m\v  situation 
liy  snlH(i|ii(iit  adli('>ioii>. 

'I'lic  niovaltif  kidney  is  usually  an  aeijinied  atfeetioii. 
Tile  relation  of  the  ori;an  to  siirroiimliiiLr  parts  is  perffttlv 
normal,  I'Xeept  for  the  increased  laxity  (d"  its  attacliiin-iits, 
w  liirli  is  due  to  a  diininiilioii  in  the  ainoiint  of  'at  snr- 
roiiniliiit,'  it  or  to  defaelinient  of  the  |icritoiie.iiiii  ti,,iii  tht> 
nnisele, 

SoiMftiin»'»«  the  adipose  eapsnie  is  larire  and  loo>e.  and 
]»rmits  of  the  inov«  nieiit  of  the  kidney  within  il  ;  in  other 
instances  it  closely  surrounds  the  kidney  and  moves  with 
it  :  whilst  in  still  .itlnrs  the  kidney  moves  within  its  adiposi- 
ciipsnl.',  and  the  capsule  also  movi-s  about  with  the  kidney 
behind  the  peritcnieiini. 

The  movable  ki<Incy  is  .dten  healthy,  and  when  found 
disi'ascd  there  is  no  positive  evidem-e  that  its  moliijitv  is 
responsibli'  for  its  patholoirical  condition.  The  disease 
may  have  preceded  and  caused  itn  nnddlitv. 

'I'his  condition  is  almost  never  accpiireil  dnriiiir  child- 
hood or  after  the  tiftieth  year.  Ft  occurs  in  w(.iinn  at 
least  five  times  as  often  as  in  men,  and  three  or  four  limes 
more  Ireipu'iitly  on  the  riirhf  side  than  on  the  Idi.  The 
<lci;ree  of  iindiility  varies  considerably,  thoiiirh.  of  course, 
it  is  always  limited  i)y  the  It'iiifth  of  the  renal  vissels. 


/ 


*  Zieipsseu's  Cycloprodia. 


-'*fr^Wi*  ^-"v:  r' .  ■*->  -• 


20 


i>isi:asi:s  or  riii:  A7/>.v/;r.v. 


Tlic  iiiTitoiifUiii  may  lie  siillicii'Uflv  loosi'  to  nllow  tlu' 
kiiliit  y  Mioviiit;  Mi'hiiKl  it  to  loavi-  its  iiatiirul  position  and 
I'iiU  l..l<»\v  till-  lirini  of  the  pelvis,  or  us  tar  forwan!  as  tin- 
anttiior  alxloniinal  parictes,  or  across  to  tlu'  ojipositr  si<k' 
of  tlic  spinal  colunni. 

In  tin-  nport  of  tin-  <'oiniuitti'o  of  (Ik-  l'atlu)l(»,iri('al 
Sociciv  of  liomloii,'  nuT.tion  is  inadr  of  a  case  in  whii'li 
tin-  kidni'V  niovi'fl  nndcr  tlu-  pcntonciini  tlirou-rli  a  space 
di'scrilu'd  as  a  circle  witii  a  diameter  of  eigiit  or  nii'.e 


inclie 


1  Anionu,-  the  causes  for  movalile  kidney  rapid  cliild-liear- 
inir  comes  lirst,  it  is  not  dilUcult  to  perceive  lio\'.  in  the 
foiviiilc  contraction  of  the  diaphn;  ;in  durinj;  vomitin,!; 
and  parturition,  and  the  c<»nse(iuent  downward  prt'ssure 
more  especially  exercised  on  tlie  liver  and  riyht  kidney,  we 
have  a  comltination  of  conditions  fav(»ral»le  to  the  di'velo]*- 
nient  of  movalile  ki<lney:  espt'cially  if  the  woman  too 
early  resumes  the  erect  jiosture,  thus  y^'w'xui^  the  displaced 
orsiau  no  time  to  hecome  tixe(i. 

\\m  will  find  in  all  your  hooks  on  this  suhjoct  that  the 
sudden  l»»srt  of  intra-alxlominal  pressuri'  after  delivi-ry  is 
looked  up(Ui  as  a  powerful  etiolou:ical  factor  in  displace- 
ments of  the  kidney,  and  to  this  loss  of  pressure  is  lariTely 
attrihuted  the  frequency  of  that  condition  in  child-heariui; 
wonuii.  This  is,  however,  a  fallacy.  If  the  kidney  has 
not  Iteeii  disjilaeed  hy  the  voniitintr  of  ]>re,!rnancy  and  the 
forcihle  ('(Uitraction  of  the  diajihrairm  upoi\  the  livi-r  and 
kidney  iluriu>r  the  lahor,  you  n'l.y  rest  assured  that  the 
relaxed  ahdominal  wall  after  delivery  will  not  drau:  the 
oriran  out  of  its  place.  The  notion  that  the  kidney  can 
be  thus  displaced  is  as  ahsurd  as  the  one  you  will  lind 
repeated  in  so  many  of  your  books  on  the  treatment  of 


'  Piitli.  Soi\  Trans.,  vol.  xxvii. 


A.\tiM.U.li:\  (}]■•   I'OSITKkX. 


21 


lll(t\V   tllC 

ition  and 
n!  as  tin- 
Ksiti'  si<k' 

lu)lc»ii:it'al 
in  wliiili 
li  a  s|iate 
:  or  iiiro 

liil(l-1»car- 
»\',  ill  tlif 
vo'nitiiijj; 
lircssurt- 
idiK'V,  wi- 

'.  (U'Vt'll*]!- 

)iiiaii  too 
(lisplac'ftl 

t  fliat  tlif 
iflivi'rv  is 
1  (lisiilac'c- 

is  larirt'ly 
l»l-l)*'ariii<; 
idiicy  has 
y  anil  tlu' 

liviT  and 
1  that  till" 
,  dra^  thr 
cidiU'V  can 
I  will  lind 
atincnt  of 


ronal  colif, — viz., '•  ( Jivi'  hot  hatlis  nnd  opiatr.  to  n-Iax 
till'  uri'tiT,  ill  order  to  lit  tlu'  stoiir  jiass  tlifouurli."  Tin* 
stono  is  Coi-cfd  tliroiiifli  tlu-  iiri'tiT  Ity  tlu'  aiTUiiiiilatioii  ot' 
iiriiiu  hi-hind  it. 

Till'  iiitliiriiir  ot"  voinitiiii;  and  rcti'hini;  in  dis|ilariiii; 
till'  kidiit'y  is  iiiiiiii'diati'ly  a|ipariiit.  \  t'vw  days  -inco  I 
i'xaniiiud  a  man  (a  |tliysiiiaii)  wliosi'  r'li:  kidiify  is  vcrv 
inovaltli'.  ill'  disroviTe'd  its  nioiiility  at  tin-  tiTinination 
ot'  a  loiiij  si'a-voyai^e  which  had  involved  ciifhtccii  days  o'" 
Hca-sickiU'ss,  with  constant  voinitinij:  and  rctcjiiim-,  and  the 
cinariatioii  was  considcralilc.  'i'lic  cinariation  no  doiiiit 
assisted  the  voinitiiiu;  and  retchiiiLC  in  dis|)!aein_Lf  tin- 
kiiliu'v. 

It  is  stated  that  niovahle  kidney  is  very  coimnon  aniont; 
cliild-heaiiiiLr  Women  of  the  poorer  classi's  in  Austria, 
l'oland,and  llolstein.  liapid  «;<'Mi'ral  emaciation  and  al>- 
sorption  of  tiu'  pt-ri-nephritic  tiit  naturally  favor  iiioliility 
of  the  kidney.  Increased  weit^ht,  either  from  a  tumor 
developed  in  the  kidney  or  from  ntones  impacted  in  its 
litivis  or  ureter,  may  tend  to  loosen  and  drair  it  down. 
The  congestion  of  the  kidney  which,  accordint,'  to  necipiet,' 
takes  place  at  every  menstrual  period,  n»ay  also  he  an 
I'tioloi^ical  factor.  This  opinion  is  shared  hy  Koherts,  who 
states  that  in  a  case  under  his  ohservation  a  disphu'ed  and 
movai>le  kidney  set'ined  to  hecome  lariji-r  and  more  seiisi- 
tivi"  to  the  touch  two  days  hefore  the  catameiiia  appeared. 
It  may  havt'  heen  the  woman  and  not  the  kidney  that 
liecame  more  sensitivi-.  In  a  ease  ohserved  l»y  Dr. 
Ritchie  and  cited  hy  Roberts,  who  was  afforded  an  op- 
portunity of  watchiiii;  the  condition  of  the  kidney  duriiii; 
two  menstrual  i>eriods,  its  size  wu.s  seen  to  he  increased 
hy  ipiite  one-half,  and  it  was  much  more  sensitive  to  the 

'  Modical  Tillies  iind  Gazette,  1C87. 


■'i 


insi:.\si:s  iiF  Tin:  Kinsiivs 


tj'l  /*/>/■,  .1. >/•..>     "I'       I  III.     HII'.W.I- 

mm 

ti.ii.'li.  Kiilarirfiiicnts  of  tli.'  liv.T  force  t'l.-  ri.ii-lit  kidm-y 
•  lowii.tliiis  .li>srctiii,<r  il].  till'  iiiTolar  tissue  whi.li  fasteiuMl 
tlic  |.eril()iicuia  to  tlii'  ImiilKir  iiiusdis.  lli-avy  liflin.sr, 
,.s|.c.'i:illy  ill  |KT>oiis  With  loose  alMloihinal  walls,  is  lial>lc 
to  start  llir  kiiiiKV  iVoiii  its  Ihm!  :  fails  aiv  ol'tcii  tin-  ratisv, 
and  iMThai-s  in  soiiu-  .-asrs  a  iHTiiicpliritis.  In  oih-  rase 
which  caiiK'  under  my  care  I  thouniit  it  jiossihle  that  th»^ 
eoiistant  u>e  of  a  s.'\viim--n.acliine  had  caused  the  trouhie, 
llu-  nioiiou  of  the  muscles  si'i.aratin.ir  the  kidney  from  tlie 
luTitoneiim  and  allowin.ir  it  to  move  in  the  retro-iieritoneal 


ried.  She  had  never  worke.l  on  the  se\vin,u:-»iiii«'miie,  aim 
was  at  present  doin.L!,- very  li,i-ht  work,  which,  however,  ne- 
cessitated her  heinjiou  her  feet  iiH.st  (.f  theday.  Uoth  ki.l- 
neys  were  movahle,— the  ri.u'ht  very  much  more  so  than  the 
Irt't.  The  al.dominal  walls  wer*'  very  thin  and  rela.-.  d,  lH)th 
kidnevs  heini:-  readilv  felt.  Tlie  ri-ht  ki.lney  would  move 
down"  t..  the  iliac  fossa  and  wIumi  pn'ssed  upon  w..ul.l 
uuicklv  rituru  t..  its  normal  position.  Its  lateral  Juotion 
was  also  considerahle.      While  the  left   kidney  was  quite 


,).\o.V.IA//>  "/••  I'OSirioS. 


•1^ 


t  ki<lm  y 

tiisti'iu'tl 

y  lifliii.ir, 

,  is  liiiMc 

111.'   I'lUlSl', 
(iMC   fUSl' 

■  thiit  tin- 

■  troultlc, 
tVuiii  lln' 

nTltdlU'lll 

Id  coTisnlt 
IS  sli^litly 
n'l'ii  mar- 
•liinc,  iiiid 
kvrvv  r,  iH'- 
r.otli  ki<l- 
(>  tliaii  tlu' 
ii;-,  (1,  Itoth 
mild  HiDVi". 

lOll     WdUlll 

rill  )m)tii)i» 
was  i[inti! 
Mu"  jiatu-nt 
*•  \v('iii"lu'(l 
wi'iirht  is 
an  attack 
•\}vv  voiiiit- 
iuii,  with  a 
H'  mobility 
1  told  this 
and  a  IV \v 

■  of  the  k't't 


Vloatinir  kiilnt'y,  tho  thinl  variety,  di']ifndrt  on  a  con- 
<j:fnital  ii'nuiilarity  ol'tlic  disposition  oftht;  |ifritoiu'iiiii,  a 
t'l.ld  ol'  tlii:'  Mii'iiiliraiu'  roiniiictt'ly  fnvtlo|iinir  the  kidni'y 
so  as  to  tiirni  a  iiicsonc|>iiron,  thns  allowini;  the  oriran  to 
float  ahont  in  tlu-  ahdoniinal  cavity  in  auy  direction. 

This  anomaly,  to  wliicli  tlu-  distinctive  term  "  II  oat  in  l!,-" 
kidney  has  lu-i'ii  apiiPu'd,  is  necessarily  associated  witli  an 
elolllfation  of  till'  renal  vessels.  .\li  intelliiediate  t'ollii, 
also  coiiiTcnital,  has  Iteeii  found,  in  which  there  is  no  nieso- 
ne|)liron,  nor  is  evi'ii  the  anterior  surface  of  the  kidney 
covt'red  hy  |»eritoiieiun,  hut,  owint;  to  some  ahnormal  ar- 
raiiircinent  associated  with  maliiositioii  of  the  colon,  the 
kidiu'v  is  left  misiiii|>orted  and  tree  to  move  hetueeii  di- 
veririiii;  processes  of  the  pei'ifoiieiim.  The  report  of  a  ca.se 
of  this  kind,  hy  Mr.  Durham,  will  he  found  in  (Jny's 
llo-jntal  Kejiorts  of  iSiJO.      These  varieties  are  of  rare 

OCClU'l'llCl'. 

l)i'n/iii)sis. — Any  movahle  tumor  ahont  the  size  and 
shape  of  a  kidney  may  he  mistaken  for  a  tloatinjf  or 
movahle  kidney.  It  is  necessary  to  hi-ar  in  mind  that 
a  movaitle  kidney  may  l>e  misshapen,  and  larjrer  or 
siiialliT  than  normal.  A  kidney,  however,  that  weiiths 
over  I'iii'ht  or  ten  oiinees  is  not  likely  to  he  very  movahle. 

Omental  or  mesenteric  tumors  may  simulate  movahle 
kidnev,  while    small   ovarian   tumors   are    less    likely  to 


no  so. 


Upon  physical  examination  oiu'  miirht  mistake  scirrhus 
of  the  pylorus  for  movalile  kidney.  The  history  of  the 
ease,  however,  ouirht  to  _i;uide  to  a  correct  diairnosis. 

r  onet'  found  a  uterine  fihroid  with  a  huitr  jii'iliele  that 
Oil  first  examination  I  took  for  a  Hoatiiii;  kitlney.  On 
another  occasion  \  had  a  patient  with  a  very  movahle 
tumor  about  tlu'  size  and  shape  of  the  kidney.  It  was 
imiiossible  to  nuike  a  positive  diagnosis,  but  iho  tumor 


•24 


/)/.v/;.i.v/;.v  o/-  THE  iiii>si:ys. 


was  tlioiitrlit  to  lie  a  iloatiiiij:  kiiliu  v  Imtli  l»_v  luysolt'  and 
liy  ullici's  who  cxainiin'il  it.  Tlir  woman  liati  honic  cliil- 
(liTii.  Slir  liail  tliiii,  lax  aliiloiniiial  walls,  and  \\\v  tumor 
conld  lu'  |.lainl_v  tilt.  She  finally  ditd  of  Mriirlit's  disease 
and  ilironic  diai'rlm'a.  .\t  tlu'  autojisy  the  tumor  was 
found  tt»  lie  composi'd  of  normal  lu'iiatic  tissue  susprndcd 
from  the  livir  \*\  a  lu'dirlc.  It  liud  never  i^iven  the 
patient  niueh  pain,  exeept  oceasionully  from  the  pressure 
of  her  tiarmeiits,  1  hav<'  never  seen  nor  heard  of  any  other 
ease  of  this  kind. 

l>isteuded  trall-liladder  nniy  he  mistaken  for  inovaMe 
kidni'y,  as  also  may  a  tumor  of  the  panrreas. 

Afti'r  all,  when  we  find  a  niovahle  tumor  in  the  upper 
part  of  the  aliilonieii,  ahout  the  size  and  shape  of  a  kidney, 
wi-  must  rely  lai'srely  for  a  diairnosis  upon  the  extent  of 
its  mohility.  and  upon  our  ahiliiy  to  pres>  it  haek  into 
the  normal  position  of  the  kidney,  where  it  is  likely  to 
remain  so  lonir  as  the  patient  eontinnes  ])erfeetly  (juii't. 
'I'his  eatniot  hi'  done  with  a  lloatiiiiT  kidm^y,  or  with  an 
onu'ntal,  niv-senti'rie.  uterine,  or  i»varian  tumor.  A  ilis- 
tended  ir.iH.l, ladder  is  not  very  inovahle  downward,  atid, 
hesidi's.  us\ndlv  tjives  one  the  feelinir  of  a  evst,  whieh 
ouiriit  always  to  he  aspirated  with  a  tine  needle. 

Trt'iidiKnt, — In  the  majority  of  eases  of  movalde  kidney 
no  treatnu-nt  is  called  for.  If  physical  exercise  jiroiluces 
unpleasant  symptoms,  perfect  (|uietmlo  must  be  enforced. 
Functional  disorders  of  the  bowels  slionld  be  corrected, 
and  unu-mia  or  loss  of  muscular  tone  sliould  be  dealt  with 
bv  appropriate  renie(lies.  A  fat-niakinu'  diet  should  lie 
pri'scrihe<l,  with  the  vii-w  of  increasinir  the  natural  packinj; 
oltlie  kidney.  Some  sort  of  truss-like  support,  sui-h  as  an 
accurately-tittint;  bilt  or  a  pad,  espei'ially  one  of  inflated 
rubber,  nniy  bo  worn  with  benetit.  The  temjiorary 
BUpiiort   given    by  si  gravid  uterud  has  been  known  to 


AMOMALIKS  OF  /'O/^.U. 


26 


diininisli  tlio  riioltility  oftlu'  kidiu  v.  In  a  sniiill  pruportion 
of  cnscs  tlic  siitli'riii«;;  is  so  t;n'iit,  liowt'Vcp,  fluit  soiiic  iiiort- 
railical  luraiis  lliaii  tlir  use  ol'a  licit  or  pad  is  callid  lor.  ( )t' 
tlif  two  opi'i'atioiis  wliicli  Iiavi'  Iu-cm  I'liiploycd  in  such 
cast's, — viz..  ncpliroi'i'liapliv,  or  fixation  ot'  the  kidiicv  liv 
sntnrcs,  and  nephrectomy,  or  removal  ot' the  kidney, — the 
t'ornier  shouhl  he  ehosrii  when  praeticahle.  (See  chapter 
un  SuriCery  ot'tlie  Kidni'V.) 


sr.MMAItY   OF   ANttMALlKS   OF    POSITION. 

ri.\i;i». 

Cuii'ifiiifiiJ.  —  .M(iri'  fnM|iii'iit  in  nun  tlitm  in  wmncn;  atl'oct-i  liy  jti'diTcnco 
the  lilt  kidiury;  a-isucliitCMl  with  ulinnrniiil  iiiTiiniri^nicnt  > if  renal  vc^si'Im, 
unlcT,  mill  liiri^i'  int<'<tini';  kidiwy  I'ri'qui'ntly  niis-lmiM'n,  as  well  hh  urn- 
j)liu'c(l ;  .«u|irii-rrnal  cMpulc  usinilly  in  it>  natural  pu-itinn,  tlnaiiiii  ncoasion- 
ally  airiiinpanyiiiic  lln'  kidney. 

Ar</iiiriil.  —  Itcsults  t'mni  pnv-isnrc  by  atiininr  nr  an  cnlartjcd  iu'ii,'liliiirint; 
orc»n  ;  I'nini  tiirht  lai'lnj;;  fnmi  a  sinldeii  blnw  or  jar,  with  .suhscijuuiit 
iiillaniniatory  adhesions. 

MOVAlMd-:. 

Arijiiiird. — More  Cn'mient  in  women  than  in  ini'n  ;  aflects  l>y  preference  tho 
rii:ht  kidney;  results  from  emaeiation,  rapid  cliild-benriiig  and  too  early 
ri-uniption  (d' ordinary  duti<'s,  tiijht  laeintc,  vomiting,  etc. 


FLOATINO. 


CiingcnUdl. — Hare. 


II.— A.NOMALIES  OP  FORM. 

^fal formations  of  tlie  kidni'y  are  mostly  oon<;enital. 
Occasionally,  however,  we  meet  with  aeipiired  eases,  the 
kidney  haviiii;  heeome  chanired  in  ontline  and  dimension.s 
in  conse(|nenee  of  disetisi'  of  the  ort^an  itself,  as  hvdro- 
nephrosis,  jiyo-nephrosis,  (•y^itic  enlari^einents,  cirrhosis, 
and  morhid  irrowths,  or  as  a  residt  of  pressure  of  tumors  or 
inorliid  I'lilarsrements  of  neiirhhorini;  viscera.  Mi.sshapen 
kidneys  are  irenerally  also  misplaced.  The  more  or  lesti 
lohidated  kidney,  already  mentioned  (pao-e  18),  is  not  uii- 

B  3 


i 


m 
■•??- 


2(\ 


j>isj:.\si:s  nr  riii:  uii>\i:)s. 


rniiiiiioii,  or  tln'  (ii'iraii  (li\i(lc(l   iiilo  two  or  tlirt'c 

imlistiiicl  ii'i'i'u:iiliir  |»orii  i_v  sluillow  (l('|ti'i'ssioiis  on  its 

SlirtilfC.        Solllctillics  ollr    kidlliV    is    t'oiiinl    to   \n-    two    nr 

tlircc  times  liiru.-t'r  tliaii  its  iMlow,  liotii  liciiiLT  otlirrwisf  |>i'r- 
f'l'ctlv  litjiltliv  ;  tliiscoiitlirioii  ih'oIimIiIv  iiriscs  tVom  dclicii'iit 
(K'\ I'loiniii'iit  ot'oiif  ot'tlif  fi'iiiil  iiftci'it's. 

Till'  viii'icty  of  inalt'oriiiiitioii  most   l'rc(|iH'iit|y  met  witii 
is  till'  so-calli'<l  lii)r»osh(H'  kidiu-y  {Vvj;.  -h,  tin-  two  oruans 

Kill.   .'!. 


)}■ 


Mi 


Ilursfshuc  kidmy,  frmn  iiiitl  i)r's  I'dllictioii  in  rnivor>itj-  Miisoum  (niiturftl  size). 

l)i'inir  t'usi'd  into  otu'  liv  nirans  oj'  an  intcrmi'diatc  tfaiis- 
vi'i'si'  ])ortioii,  usually  consistiiiir  of  triK'  ri'iial  srcri'tini; 
strui'tiuv,  tliouii'li  somi'tinu's  nu'ri'ly  of  oondi'iisi'*!  filn-oiis 
tissue,  wliii-h  I'oinu'i'ts  tlii'ir  lower  ends  across  the  front 
of  the  vertebral  eolumn  so  as  to  form  a  eresceiit  or  horse- 
slioe-shap'jd  body,  with   the  coiioavity  dirootod  upward. 


'IL 


.1  vou.i/,//;.s  or  SI  Miii:ii. 


27 


rw  ISC  |K  r- 
1  (l»'li<'iciit 

met  witli 
,()  (>ru:!iiis 


III  r:iii'  iiistiiiiifs  till-  tniicavitv  is  dinifcil  duwiiwiinl,  tlic 
ii|i|M  r  cutis  iM'iiiir  miifcil,  or  the  (•(UiinTtiiiL;'  l«ii(li;r  inav 
I'Xti'iid  rrtiiii  tin-  liiliiiii  nfuiu'  kiiliifv  lu  that  ot'  tlic  oiIht. 
Tlif  two  lialvi's  (il'ji  horsc'slidc  kidiitv  arc  iisiiallv  coniiilcfc 
ill  tliiiiisflvcs,  liaviii";  cacli  a  distinct  pelvis  and  ureter. 
Mi-st  l'rci|iiciitly  the  ureters  descend  in  iVniit  ot'  the  Iraiis- 
\cisc  |M.rtion.  when  lliis  unites  the  lower  ends  of'the  kid- 
iievs;  more  raielv  tliev  |iass  hehind  it.  In  a  few  exeeed- 
iimlv  rare  eases  the  sii|>eriiiinierarv  renal  |tareneh\nia  is 
not  united  to  the  tw(»  kidiievs,  so  that  the  middle  |.ie,'e 
constitutes  an  inde|ien(lcnf  kidney,  ri'ceivint;  Itjood  iVom 
liolh  the  lateral  parts,  hut  posscssiiii;  also  imh-pciidciit 
vessels. 

There  arc  a  few  cases  on  record  wlicrt'  one  or  hoth 
kidneys  have  hail  two  distinct  pelves,  jn  must  instances 
tliesi'  have  lie*"ii  louml  to  unite  so  as  to  t'orni  one  sini{h' 
ureter.  Ill  a  case  reported  hy  |)r.  Kvarts,  however,  hoth 
kidiuys  were  furnished  with  two  distinct  pelves  and 
ureters  which  ended  separately  in  the  hladder,  all  four 
ureters  heiiii;  pervious. 


52^^^ 


atiiral  size). 

late  trans- 
secri'tini; 

I'd  tihroiis 
the  front 
or  horse- 

I  u[)Wiird. 


Ill  — ANoMALFKS    OF    M'.MBKR. 

Siipernumerury  kidneys  with  separate  hlood-vessels  and 
oxcrt'tory  ducts  are  occasionally  met  wi.h,  while  in  a  niiiii- 
liir  of  instances  only  a  siuirle  kidney  has  heeii  found.  As 
loiiir  :is  this  remains  healthy  there  is  no  derangement 
of  the  urinary  function;  hut  should  it  hecome  diseased  or 
itri  excretory  (hict  ohstructed,  tiital  iiruMuia  will  rapidly 
su].ervene.  The  term  "solitary  kidney"  is  sometimes 
iipplied  to  all  eases  in  which  there  is  only  one  renal  oriran. 
Ordinarily,  however,  it  is  limited  to  fusion  of  the  two 
kidneys  into  one  mass,  entire  ahseiue  of  one  kidney  heint; 
desiirnated  as  "  iinsymnietrical  kidney."  The  f(U-mer  is 
always  eon_.,^'nital,  the  latter  usually  so,  except  where  one 


28 


JHsHAs/-:s  or  Tin:  kihskys. 


!  ill 


kiiliifv  liiif*  lu'cii  rciiiovid  l>v  in|(lir('<'tuniy  or  (U-Htrowd 
liy  disciist'.  ('(iiiiiciiitMl  iiti'o|iliy  or  rmliiiU'iitaiT  kidin-y 
iM'loiiLrs  |inicticiillv  to  the  saim-  class. 

Ainoiiir  tlif  I'ccoriird  casts  of  solitary  kidney  \vc  find 
every  coiiccivalilc  variety  of  form  and  dcirri'c  of  fusion, 
from  tlic  ordinary  liorsi'shot'  kidney  (/•(//  //////"//Vo/z/f/.v), 
whicll  represents  the  lowest  irrade  of  fusion,  to  tlie  coin- 
jih'tely  uiiiti'd  variety,  in  whieli  the  two  (nuans  form  a 
siiiijle  disk-like  mass  provideil  with  a  donlile  or  single 
|ielvis.  hr.  I>roe>ike,  of  Merlin,  riports'  a  case  of 
S-sha|ied  fusion  of  both  kidiu-ys  [nn  sii/mniili  itiii),r()un\>^t'\i\if 
in  union  l»y  wunl  tissue  Itetweeii  the  lower  end  of  the  left 
kidney,  which  occu|>ie<l  its  nornnd  position,  and  the  upper 
end  of  the  riirht.  which  lay  wholly  to  the  left  of  the  ver- 
tehral  column,  with  its  hilum  dii'ected  to  the  left  and  its 
convex  liordir  to  the  riirht.  On  the  anteri(tr  surlace  of 
this  douhle  kidney,  which  i-Ntcuded  from  lietwcen  the 
eleventh  and  twelfth  dorsal  vertehne  t(»  the  middle  df  tin- 
last  lumhar,  tlu'  line  of  uidon  luMwcen  the  two  organs  was 
indicated  hy  an  ohlitpie  furrow  runninir  downward  ami 
outward  (to  the  left),  ami  lodiriii.tr  in  the  left  iireti'r.  the 
posterior  surface  heini;  perfectly  smooth  throui^liout.  A 
much-divided  renal  artery,  eiiterimr  at  tlu'  hilum,  supipTu'd 
the  ni>per,  or  left,  kidni'y,  while  the  lower,  or  riuiit,  re- 
ceived two  distinct  arterial  trunks,  one  arisinir  from  the 
norta  just  above  its  Itit'urcation  and  eiiterimr  the  convex 
hordi-r  of  the  kidney;  the  other,  a  branch  of  the  hit  com- 
mon iliac,  ti-rminatim;  near  the  lower  hortler  of  the  hilum. 

in  iinsyminetrical  kidney,  or  comrenital  alist'nce  of  one 
orsjfan,  the  renal  vessels  as  wi-ll  as  the  nn-ter  are  likewise 
wantiniT.  Where  these  exist,  the  case  may  lie  jiresnmed 
to  be  one  of  atrophy,  coiiifenital  or  acquired.     When  the 


'  Viirhow's  Arfhiv,  Nov.  1884. 


i*t^«aM«»M 


- 1. vow.  I A //.'s   o/'    M  MltHh: 


•Jll 


ttiily  ('\i.-tiiiir  kidiii'V  lias  tWd  urctfi's  iiinl  a  doiililc  sit  <•!' 

Ill l-vosfls,  it  iiiiiv  lu-  Pi'irardtd  as  solilarv. 

A  siiiirlc  kidney,  of  w  liiclicvcr  variety,  is  in  liic  majurify 
dl"  iiistaiii'cs,  liiit  nut  always.  liy|K'rtr(»|thiiM|,  and  may 
attain  an  enonnoiis  si/.i',  weiirliinu;  sivcial  pounds.  It  is 
iVi'ipifntly  inisplaied  and  more  of  less  almorinal  in  form. 
It  slioidd  lif  renivmln'ivd  tiiat  anomalii's  of  the  kidney  afe 
often  asso(iat».'d  with  sutu*'  def»'et  of  the  irenerafive  ori^'ans, 
ami.  uliere  tlie  latter  exists,  tlie  Utmost  caution  slmuld 
lie    eXereised  wlier*'  nt'plireetomy  is  eonteni|ilate(l.  lest    an 

oidy  kithu'y  lie  removed  and  the  patient  he  left  without 
any  renal  or<ran. 

Alisenee  ot'  lioth  kidiu'ys,  as  well  as  of  the  iii'eters  and 
liladder.  has  oth'U  heeii  found  in  still-horn  ehildreii.  espi'- 
eially  in  acephalous  iiuuisters.      M.  Moulon,  of  Trieste,"  has 

I't riled  the  easeot'a  irirl  who  dieil  at  the  at,^•  of  fourteen 

of  ehionie  pistro-enteritis,  in  whom  neither  kidiu'ys  iior 
ureters  were  found.  The  hhnhhr  was  also  wantinsj:;  anti 
the  undiilicus,  from  which  there  had,  since  hirth,  heen  ii 
continual  discharir*'  <»f  u  uriiu'-Iike  liquid,  was  situated 
wlu're  the  luons  \'eneris  usually  is,  the  sym|ihysis  puliis 
heinir  replai-e(l  hy  a  wide  irup  covered  only  hy  the  skin. 
The  extenud  ire  itals  were  very  defective,  and  the  anus, 
which  was  itiordinately  lurire,  opened  where  the  vai^inal 
oiitice  shouhl  have  heen;  hut  the  uterus,  ovaries,  and 
Fallopian  tuhcs  were  perfect.  M.  Moulon  concluded  that 
the  hlood  in  this  casi'  pive  uji  to  the  liver  those  constitu- 
ents whi<'h  Lfo  to  form  the  urine,  and  that  they  were  con- 
veyed hy  the  umhili<"il  vein  to  the  undiilicus,  and  there 
excreted.  The  liver  was  <fanirri'nous,  as  were  alstt  the 
intestines  in  spots  throuirhout  their  extent.  The  pancreas 
was  converted  into  a  sac  of  pus,  and  the  ^roat  omentum 
was  in  part  destroyed. 


'  Ari'hivrs  GeinJralcs  do  Mnducinc,  t'>me  xvii.  p.  424. 
3» 


f 


SKCTION    II. 

DISEASES    OP    THE    KIDNEYS. 


I 


1! 


"^ 


(   II  A  I'TK  li    I. 

m:i'|||i  \i,<;ia. 

N'KI>lllt.\l..;|A.    nr    ll.iin.l^rii,    ,,|'   ,i„.    |.i,|,„.v     i,    .,    „.,„,,. 
i'l'l''"'!  ill  it  jrciici-iil  wnv  f,,  ,,j,ii,  in  t|„.  kidm-v. 

lvnnl.,MiV.— |5y  (•;„•  ll,.'  IM..st   f.v.|ll..l,|   ciMlMS  uf  Ii..|,l,ri.l- 

,iria  i.ivivni.l  .i.I.uli.^.iilu.r  lar-c  ,:,I,Mili  in  tli..  jM-lvis  or 
t^iiialKr  oiHs  ill  111,,  iiiiiiifl. rolls  tnlmlcs. 

_     Til,.  ll,.x(    ninsl    lV..|MrIlt   .illlX'S  ofpiiin   aiV  11, .u    Ulowllis 

111  III,.  ki.liii..\ .— .aiir.r,  ,.ysti..  .Iis,.asi.s,  ,.(<■.  W,.  lii„|  il,.,t 
.iroiity  ki.liH._v  is  sul.j.vl  lo  riv.|iu.iil  iH.|,l,raI-i;,s,  „s  ar  also 
tlir  ki.lii,._vs  oC  tlios..  a(l(li..(,..|  to  al.o|„,lisi,i:  i|,:,f  of  ili,. 
«'..niur  may  1...  <|,i..  lo  tl„.  .•..ntra.t,..!  .•oii.lition  of  ih,. 
ki<liitv  ..r  to  iriitatioi,  ,aiis,.(l  l.y  .Icposits  ,.f  .rvstais  of 
mat,'  ofs.Mlimii,  wjii,.),  ii,,.  t;„i,„l  in  „.,.,,.,!  „„.m1.,"is  in  fl.c 
intcrtulmlar  spa.Ts.  I,,  tli..  latter  .asc  ll„.  ;,  in  niav  W' 
•I'lf  lithrr  to  III,,  irritatintr  <|"itlity  of  tin.  uriiic  or  t(."  tli,. 
liyi.iia'i.ii..  roii.litioM  of  th,.  ki(lii,.y.  \\\.  l,;,v,.  aliva.lv 
<»l'su-v,..l,  ill  st.i.lyiMir  ,l„,  iiiiatoiiiyof  tlu'  ki.liu'V.  that, 
fn.iii  flio  nrraiiir.iiu.Mt  of  its  iu.rvr-sii|,|,lv,  a  (lisf,.|„I,.,i 
n.ii.lition  of  tlu-  lilood-vi.ssi.ls,  fithcr  active-  .".r  iKissivi-,  miist 
iit'ctssarily  iiroduc,.  pain. 

A  inoval.l,.  or  floatii.^  ki.liu'y  often  ijivcs  r's,.  to  pain. 

Sv.Mi'TnMs.— Pain    is   th."    pathoiriionioiiic  symptoni   of 
nq.hral.iria ;  that  is,  pain  of  a  sharp,  soVfrc,'lan.iiiatii 


80 


'fe' 


SF.rilKM.UlA. 


SI 


luitiiri'.  I'liiii  (if  II  (lull,  li.iivy.  iicliini,'  ( liunicttT  i-  not 
culled  iicii|iriili;iii.  'I'll.'  |>iiiM  (illcii  I'dlhiws  llic  line  df  tin- 
iiitU'r  to  llic  iri'diii.  ill  times  iinxliieiuir  |,i,;ii  'm  (|,,.  testicle 
or  ill  ilie  liciid  of  tlie  Ileitis,  or  exteiMliiii;  |iiirtiull_v  iiroiiiid 
llic  lioily.  'I'liis  is  pjiiticiiliiilv  the  c:ise  with  tlie  inteiii- 
|>crati',  who,  diiiiiii,'  or  lollowini;  the  attiick,  (  .\|ici'ieiice 
fVei|ii(.|it  iind  |iiiiiil'iil  iiiirtiii'itioii,  the  urine  lieinir  hiwh- 
colored  iiiid  fiirliid.  In  the  iiit.iii|ieriite  the  ne|i|ii-idu'iii  is 
occasionally  acconi|ianie(|  l.y  heinorrhasri'.  c\en  u  hcic 
there  is  neither  stone,  iroiil,  cancer,  ikm*  tiilierciilo.-is.  In 
this  class  of  cases,  however.  We  arc  apt  to  tiiid  alhiinicn. 
I  may  add  that  ih  phial^'ia  is  often  acco!n|ianied  hy  Hovoro 
voiiiitini;'  or  rt'tcliini;. 

IM  VdNiisis. — In  niakinir  a  diaLfnosis  it  is  necessary  to 
rciiieiniicr  that  pain  in  the  riirht  kidney  miirlif  be  iniM- 
taken  for  heptaliria,  or  passai^i' of  irall-stoiic,  for  the  severe 
pain  of  olistfiiction  of  the  ascendinir  colon,  or  even  for 
jiaiii  in  the  appendix.  Xephraliria  on  the  left  side  is  not 
HO  a|it  to  he  mistaken. 

For  the  diairiK'sis  of  the  ditfcrent  conditions  tliaf  irive 
rise  to  iiepliral-fia,  we  shall  find  a  detailed  account  of  tlu' 
fyinptoin.s  under  their  icspcctive  luadini^s.  ns  stone, 
tuherculosis,  etc. 

Titi:\r.\ii:.\T. — The  indicjition  for  treatment  is  to  relieve 
fti*'  pi'iii  Heat  is  sometimes  etHcacioiis.  Morjihine 
Hhould  Ih'  administered  liypoderniically.  that  heinir  tli»' 
hest  way  to  administer  this  analiresic  in  ncphraliria,  as  we 
have  seen  that  the  pain  is  apt  to  cause  excessive  vomitini;; 
or,  where  a  syrinire  is  not  at  hand,  morphine  or  opium 
may  lu'  <;iven  l.y  tin-  rectum  in  the  form  of  injection  or 
suppository.  The  desired  relief  may  hi-  ol.taiiied  hy  the 
inhalation  of  chloroform  (M\ ether.  Further  indications 
for  treatment  will  he  found  under  the  headinirs  of  the 
diseases  of  wliich  nephralgia  form.s  u  imjminent  symptom. 


■.•71'nin  ff  1-.  Ill, 


f 


i 


iV2  /)/.va;.iskn  oa  Tin:  hn>.\i:)s 

(11  A  i"i"  K  i:   I  I. 

II YI'KIl. K.MIA — foNilKSTIoN    til'   nil;    KIUNKVS. 
HkXAI.   lis  |n'r»'lllill   IIIIIV    lir  ili'tivi'  <'!■    |iilSHivt', 

Ivriiii.nia  —  .I'/'Vi. — III  inkiiiir  up  tlic  siiltjcit  nl'  liv|Mr- 

ICIIliil.  lit   nil'  aifllill  illl|it'(>r4  llpnll   Vnll  the  illl|Hi|'tilll>  r  of  a 

tlii>i'<>iii:'li  iiiiili't'siiiiiiliti!.''  lit'  tilt'  rii'i'iilatiiiii  in  tlif  kiiliirv. 
(Sif  iliaiilir  (til  Aiialmiiv.)  Ni»  ilmiltl  llif  larirf  »i/,i'  ol' 
tln'  ifiial  iirtt'iT  Hicilltati'M  li_\  lufa'iiiia  w  luir  tin  re  i^  ttvcr- 
arlioii  III' till'  Inarl  ri'niii  li_\  |M'i'tri>|i|i,v  ol' tlii' tii'iran  m  riHin 
ii\t  r-.-liiniilati(iii  Iivsuili  ilniLr'^aHiliirii'.lis ;  I  nit  inativtli  UiTf*, 
siicli  as  liii'|it'ntiiii>,  laiitliar'nlt's,  i  'iiD.ilia,  t  iilitlis,  ami  rar- 
liiilif  aciil,  may  taiist'  liyiiti'Miiiia.  artinir.  Iinwfvi  r.  l.y 
(lir«'it  irritatittii  tir  stiimilatitui  nf  ilif  kiihiry  itM'If. 

!t    may  lie  jiriMliiciil   liy  iiijiirit's,  rtiial  i  ali  iili,  or  cnii- 

I'lrtliiiis  in    tile  tnliiiji's.  ami   imt    intVri|in'ntly  it   a mi- 

jianii  s  till'  aciitt'  int't'ctioiis  ilisrascs.  ( >t'tlii'  amtf  intt'i'tiniis 
iliscasi's.starlatiiia.i'lioK'ra,  ami  (li|tlitln'ria  imwt  lVi't|iU'iitly 
|ii'imIuii'  liy|ii'ni'iiiiu.  Kxposiiii'  ot'  tin'  liody  to  smldfii 
«'liain.''t'-*  of  tt'iii|ii  ratiM't'  is  aiiotin  r  caiisf  ol'  niial  liypt'i-- 
ii'iiiia  ;  ami  I  iiniy  rtiniinl  you  that  this  conilition  always 
_'ft cttlt's  acnti'  intlaininatioiis  of  the  kiiliny. 

I'lTssiirc  u|ioii  till'  alMlominal  aorta  liclow  tin-  renal  axis 
must,  of  roiirsi',  iirodufc  imi't'ast'il  lilooil-jii'i'ssiifi'  in  thf 
kitltnys.  ami  coiisciiui'iit  liyiicru'inia. 

J'li.^.sii-i'. — I'assivc  hyiKiainia  is  causftl  Ity  'iirh  tumors 
ill  thf  alxltimiiial  cavity  as  may  imss  ii|ion  or  inti-rftTi' 
with  the  iiifi'Pior  vt'iia  cava  ahovc  the  ciitramc  ot'  the 
ri'iial  Veins, — aneurism,  cancer,  etc 

Diseases  of  the  renal  veins  may  oh.struct  the  circulation 
ami  |iro(luee  passive  liy|terieiiiia  ;  ami  (liseast'>,  of  the  liLjht 
nitle  of  till'  heart,  sucii  as  fatty  (U'^oiienition  and  dilutution 


I   iili  Wiiili      I  n  •  I" 


w^VtfwM-^m^vaMVCii 


in  I'Kii.r.Mi  [—cttsuF.xrins  or  riii:  Kin.srys      jj.j 


KYf*. 

■I  III'  liv|n'r- 
irtiiiifi'  i>\'  a 
till-  kiiliicv. 
I'lTf  >i/.c  ul' 
WW  i.i  ovci"- 
iraii  III'  tViiiii 
iiaiivtIriiLrs, 
lis,  ami  lar- 

oWcVcl',    li_V 

M.jf. 

iili,  or  cdii- 
V  it  ai'CKiii- 
If  iiili'i'tiuiis 
1  tVi'i|iu'iitl_v 

to    slKJilcli 

fiial  liyiH'i- 
ilidii  alwavs 

(•  ri'iial  axirt 

■IHUIT  ill  till' 
llill  tllllinrs 

or  iiitiTltTo 

nice    III'    till' 

'  firciilatidii 
of  tiu'  rii,'lit 
(I  dilututioii 


•  ir  iiiilnil  iciriiiu'itatiMii,  wliiili  iirmliKf  iilwfnirtiiin  i.t'  flic 
|iiilriMiiiarv  rinnlatioii,  will  liriiii;  alMiiit  tlif  saiiif  r."«iilf. 

>>ii  aUo  limy  any  nr^'aiiif  disiaxc  (»f  thr  Iiiiii;s  >\|ii<|| 
III. -fill. trt  flic  r\^Ut  iH'arf,  as  filiroiis  iilithi^is,  rxn-^sivi- 
|i|tiirific  uillu-MioiM,  tiii|i|iysciiia,  <lir<.ni.'  l.nuiclilf'H,  »'fc. 

SvMiTiiMs — Aifin. — 'I'lic  |iafii'iit  will  i'oiii|iIaiii  ofiicliimr 
paitis  aliniit  flic  IniiiH,  Hniiifliuu's  fxtcinliiiir  almux  Hie 
tMiirst'  ..f  thf  iirrtrrM,  ur  radiatiiiir  to  iJi.-  hips.  'I'liirc 
is  usually  ffiuK'nicss  uii  pn's^iir*-,  ami  iiof  iiilVt'.ni,.|if|y 
nausea,  an. I  lurliaps  voiiiifiiii;,  ai('oiii|iaiii(>il  or  imt  l.y 
liiailai'lii'. 

No  iloiiiil  flu-  iiicrcasid  t|iiaiitity  otiirim'  that  is  iisiiallv 
|ir«'s.i>f  in  iroiify  kidiiry  is  owint;  fo  the  Iiiir|,  pnssmv 
from  III.-  |pyi.,.rtro|.|ii,..|  heart.  (  hi  the  oih.r  liami,  we  not 
iiifrf.|iifiit|y  tiiid  1,1, „„!  ill  flu-  iirim-  wlicri'  flii-iv  is  active 
hy|itrii'iiiia,  iiartindarly  in  that  of  acute  iie|ihritis,  in  the 
hy|icru'inia  of  flu-  iiitemiierafe,  ami  in  that  following 
injury. 

/',/v,v,V,._li,  this  condition,  aside  from  the  syiii|.t(»nH 
of  the  lesion  which  causes  the  hyptnciiiia,  there  will  ho 
a  diminished  excretion  of  urine,  which  will  he  porter- 
'olorcd,  owinir  to  the  presence  of  disiiitcirrati'd  hlood,  and 
will  contain  sonic  uIImiiikmi  und  ('asts. 

Care  must  he  taken  not  to  mistake  this  for  the  urine  of 
acute  |{ri_i;ht's  disease.  An  examination  of  the  heart  imiv 
reveal  the  cause  of  the  passive  coiiLjotion  or  renal  ol.stnic- 
fi<in.  The  heart  will  he,  perhaps,  in  a  state  (.f  fatty  do- 
t'eneration ;  or  there  may  he  dilatation  ..f  the  ri-rlit   iicart 

*"''«» f.iranic  disease  of  flu-  liiiitrs,  ,,y  a  severe  mitral   re- 

guiiritation  may  he  produein,«r  the  pulmonary  ohstnicfion. 
In  these  conditions  of  the  lieart,  not  only  the  kidneys, 
I'Ut  also  th,.  liver  and  the  jiortal  <Mrculati,iii  suffer  from' 
the  passive  con<restion  ;  and  it  is  this  fact  that  enaliles  us 
to  differentiate  hetween  passive  and  active  eoiiirestioii,  as 


«iW6<»«Sn  *ff«wn 


J 


^fi 


3^  DISIIASF.S  i)F  THE   KIDSKYS. 

Nwll  asto.listinun.i^li  tlu'  iiihiinu'iM.f  i-assive  o.iii:v>tiuii 
tVuiii  thiit  oi'afuti"  I'>ri,i,^lit's  disciisi'.  _ 

l'\Tllul.u,iV  — .l-Z/'T.  — In    Urtivr    1. VlKTirillii.    tlu"    IDorl.ld 

,.r,,rc.>s  lirs  iiuiinlv  ill  llu'  renal  xxyWvw^  and  tlu'  artrrirs  of 
iIh.  Mali.i'-l.ian  tnfts.  Tl.e  ki.liH'.v.  aiv  tai-v,  nmist.  and 
„,•  ,  .lark  iTd  .■ulnr.  Tin- cai-^uU- stril^s  .asily.  On  s.t- 
,i,,n  tlir  Malpl.trliiiin  Lndirs  an-  ivr..-iii/A'«l  as  dark-iv.l 
iM.ints  that  dot  tliv  surfafc 

/>„,,,v,v,._In   passivi-  livi.eni'niia,  which  has  its  scat  iii 
,1k-  veins,  tho  kidm-vs  in  the  c.rly  sta-os  may  he  enlarged, 
hut    later  will    U'  ..f  normal    or   diminished    si/e.       1  he 
whoU'  oiran  is  tinn,  with  an  elastic  or  tou-h  feeliiiir,  and 
is  of  a  shitv-hlue  color.      The   capsule   is  easily  removed. 
On  section!  the  Mali>i,u-hiaii  ho.lies  are  seen  to  he  i.roim- 
neut,  hut  the  most  marked  changes  are  in  the  medulla, 
the  bases  of  the  (.vrami-ls  sh-.wino-  marked  coii-estioij, 
an.:  the  deei.lv-eon-ested  vessels  shinin,i;  cut  very  i.roiin- 
nently  between  the  bundU's  of  urinifen.us  tubules,  -ivm- 
the  tissue  a  striated  appearance. 

In  (d.l-standimr  c-ases,  irivijular  pale  patches  makc^  their 
.,,,,,„nnice,  and  the  or-aii  may  feel  almost  fibroid. 

,.,,„...,osis.— In  active  hyperiemia,  the  pro-nosis  depends 

on  the  excitin-  cause;  when  this  is  tunetional  the  hyper- 
romia  is  simplv  transitory. 

In  passive  livpenemia  we  must  .jud.ire  of  the  pro-nosis 
by  a  consideration    of  the    disease    which    pro.lnces     ae 

obstnietion.  .  .      , 

'p,ij,v,.MKVT— Jr//r,.— In  treatin.tr  active  hypera-nna  the 
indication  is  to  remove  the  cause,  if  possible.  Where  it 
dev-ends  upon  hvpertrophy  <.f  the  heart,  for  instance,  we 
nn.st  modifv  the  heart's  action.  When  it  acconipa.ues  the 
acute  infectious  diseases  there  is  no  special  mdieatmn  tor 
treatment.  Where  injury  is  the  cause,  absolute  (puet  and 
rest  will  be  necessary,  with   cold,  eupping,  or  perhaps 


^;i 


:rrr!?ir?.araffSK3"ws«v-;-v  ■  -j^ 


y;,7'/.;A'.7:.U/.l— ro.V(./>77".V   of   Tlli:    A7/'.V/;).s 


:{.') 


till-   iiiorliiil 

•  ,  moist,  iiiitl 

ly.      On   si'C- 

iis  (Uirk-ii'tl 

IS    its   srilt    ill 

lie  t'liliirirc'd, 
1  size,  'rill' 
I  tViTinir.  iiixl 
;ily  rcMiiDVi'il. 
to  111'  jiroiui- 
tlif  uiciliiUii, 
il  conicstiou, 
1  very  |iroiiii- 
ihulrs.  <:iviii!:: 

08  rnnkv  tlioir 
filiroid. 

miosis  (U'|n.'ii<ls 
iiul  the  liyi'tT 

tilt'  ]>roirnosi9 
prodtici's   I'ho 

lypi'Tivniiii  the 
)io.  NVlicri'  it 
)r  instancL',  wo 
.'Oonipiuui.'stlio 
indication  for 
i)luto  (luiot  and 
ig,  or  \(orliaps 


1,„,1ks.  ai-l.ru'd  to  iIk-  hark.  -ivr  sonHtlnu-  t..  allay 
,,,„  ,„i,i.  avoid  stiniulauts,  and  o-ntin.  tlu-  patiHit  stnrtly 
,„;„„„.nitro.vuou>  dirt.  Ian.  in  tla.  l.al-it  ..f  koopm- 
tiiv  iKiticnts  on  tliin  ri<c  <:-i'nrl.  _  _ 

■/»„..„,.— In  rasc-s  whi.'li  d.'i.rnd  on  dilatation  ot  tlio 
,i„-l,t  .ido  of  tiif  hrart  or  on  fatty  d.-.-nrration.  \hv  patient 
n^'iudlv  .v.inifrs  l.oth  alroholir  and  h.art  stiniulant.:  tl,at 
i,  it  is  tlu-  hrart  that  n.ir.irrs  trcatiniMit,  rather  tiian  tlio 
k;,hHVs;attlu.  sanu- linu.,  tlu.   portal  .innlat.on,  hasn.^ 

MNorMHM'io.H.Mlthrl'ii^^'^-^'''''''.^'*''^^'''"' '*'''"''•'' '''■'•''''''' 
l,v  a  sdiiu-  cathartir.      Whriv   thr  passivo   ron-.-tion   is 
;,„,„,,„1  l.v  tn.uors,  anrurisn.,  vU:,  it  is  .nttrrly  a  n.att.r 
.,,■  ..Ualin-  with  tlK.  oanso,  whh-h  wr  may  or  may  not   1m- 

iihlo  to  ri-movi'.  ..    1-   • 

\m..n.-  hrart   stimnlants  we  havo   tlu-  .-hoi.v  <.t    digi- 
talis ron\.illaria,  stn.phanthus,  ratU'i.u.,  nitt'o-o'lyrvriiiotc. 

\h.nv  patients  wlim  onr.  rolievcMl  hy  stimnlants  will  l.o 

o-.va'tlv  lu-notitod  hva  systematir  .•onrse  ot  heart   t..nirs, 

Thr  hrst  ..f  wliirh  ill  m.v  iiai.ds  has  h.vn  ^try^hn^H^  -'ven 

with  i.hosphorio  arid  t<.  older  patients  ami  with  in-ii  to  the 

vonn-er.      I    usnallv    he-in  a  eonrse   of  stryhnine   with 

;ins.s'~of  from  ..ne-tiftieth  to  one-sixtieth  of  a  -ram,  in-Mvas- 

i„...  to  one-thirtieth  or  <.ne-tweiity-tifth  of  a  -ram.     Oeea- 

sim.allv,  h..w..ver,  it  produees  headaehe  :   in  this  ease  4UI- 

„i„e  will   he  found  to  he  a  -oo.l  snhstltute.      I  ha'--  also 

,„n,id  patients  who  took  nnx  vomi.-a  and  phosphorie  aei.l 

with  heiietit,  in  whom  stryehnine  prodnee.l  liea.hiche. 

As  the  amount  of  urine  socrotod  depends  ehietly  upon 
tl,,  de-ree  of  pressure  within  the  vessels  ..f  the  -lomerulo, 
it<  .oeretion  neeessarilv  heeomes  nioiv  prof-ise  in  that  lonn 
of  renal  hvperromia  whh-h  involves  the  anerial  s^st.m  ot 
tlu.  kidnev,  ineludin-  the  vessels  of  the  Malp.-h.an  tiilt. 
1„  sneh  eases  tho  pressure  in  the  -lomerule  is  hardly  ever 
suiheieiit  to  oeeasioi.  transudation  of  alhiniieii,  ur  to  rup- 


SC!05»P8K3«tira»^-;it>'  ^■.  T 


p.  tf.i;>.i»SK2i«s«rr  ■*iA5*a:.'^*^--^J*^J» 


T' 


:{•; 


i>isn:.\sr.s  or  riii:  kidsevs 


tiirc  flic  Vfssi'1-i  iiiid  cuii.-f  fxtnivasiitiiiii  of  lilooil  into  the 
Miil|iii:'lii;iii  coriiiisclcs. 

A  vci'v  (litlri'fiit  ti'jiiii  of  s_viii|>ttiiiis  follows  u  I  ion  a  iiiod- 
iTutf  (jcurrcr  of  nltsfriirtiri  nii/oi'ifiiiKiif.  In  almost  I'Wi'y 
case  of  olotniftioii  of  tlic  Veins  of  tin."  kidiu'V,  flic  (K'lriH'i- 
of  tfiisioii  uitliin  its  arteries  is  verv  small,  ;;;nl  tlicre  is  a 
tliiiiinutioii  iiisttad  of  an  incn'asc  in  the  secretion  of  mine. 
( )n  tlie  other  hand,  tlio  ntrain  npon  the  caiiillaries  ln'conies 
exeeedinii'lv  severe,  since  tiicv  cannot  diseharire  their  con- 
tents into  the  alreadv  overloaded  vi'ins  until  tin-  jin'>sure 
within  them  exceeds  that  in  the  veins,  lltnce,  not  oidy 
doi's  the  I'lasnia  of  tlu'  hlood  escape  from  them  into  the 
tultnles,  so  that  the  scanty,  concentrated,  tlark-colored 
nrine  contains  alhumen  casts,  hut  the  (U'licati'  walls  of  the 
capillai-ies  u'ive  way  het'ore  the  strain,  so  tliat  the  urine  is 
also  fidl  ot"  Itkuid-eoriiusck's.' 


CIIAPTEH    1  I  I. 


ll.K.MATl  UIA. 


TT.KMATIHI.A  is  tlie  term  emjiloyed  to  denote  the  iiresenco 
in  the  nriiu'  of  Mood  derived  from  any  j)art  of  the  urinary 
tract. — whether  from  the  kidneys  {ii(iiliri>rrli'i(/''H),  the 
ureters  (iinfnrrliiK/id),  the  Madder  {ri/sf(irr/<(ii/!ii),  (ir  tlie 
uretlira  {>intlifiirrhn;/i<i). 

Ivriui.ixiv. — We  not  intro(|Uently  find  hiiMuaturia  in  liy- 
peru'iuia,  either  active  or  passive,  as  well  as  in  cases  of  con- 
tusions, wounds,  and  other  injuries  of  tlie  kidneys.  Heavy 
liftimr  or  ovir-cxertion  sonietiiuos  jiroduces  liemorrhairc. 
Keual   calculus  is    one  of  the  most  coinnioii  sources  of 


'  Nieincyur. 


1.eirrj-«.,Jk»r.?Wi«wa^»-jWO9W*0to4W!»t''tairi«KM?«»lt^ 


(Ill  into  tlio 

|i(iii  a  iiiod- 
iiitist  evcrv 
tlif  di'iriTi' 
il  tliiT''  is  ii 
on  of  iiriiii'. 
ii'S  ln'coiiu's 
t'  tlicir  coii- 
lii'  invssuiv 
ce,  not  only 
•ni  info  the 
liirk-coloroil 
Willis  of  tilt' 
tlio  uriiK'  is 


he  prcsoiu'o 

the  urinarv 

rl'tif/ia),    the 

f/ifi),   <ir  the 

turiii  in  hy- 
.'iises  of  c'on- 
■ys.  Heavy 
lemorrhaire. 
sources  of 


ILKMATl'IilA. 


;{7 


lueinatiifia.  In  ironty  j)atieiits  with  dist-ased  arterii-s,  this 
contlitiou  occasionally  arises.  It  is  not  fr»MiMint  in  ihc 
course  of  tnlHilar  nephiitis,  except  in  initial  active  hyper- 
!eniia,orin  patit'nts  addictt'd  to  the  exct'ssive  use  of  alcohol. 
'I'uhcrculosis,  tuniois,  an<l  cancer  of  the  kidney  causi' 
di'struetion  of  tissui-  and  luinorrhai^e. 

( )f  thi'  hlood  _i,'lan<lular  dist'ases  and  diseasis  of  nutrition, 
imrpiira  laeniorrhatricii  and  scurvy  are  the  most  apt  to  In; 
ai'<'onipanied  hy  Inennituria.  I  have  had  sevi'ral  cases  ot 
ha-niaturia  durini;  the  conircstive  staict'  <»f  nnilarial  fever, 
and  have  set-n  maliiruant  attacks  of  an  acute  infectious  dis- 
ease ]iroduce  it.  Nor  must  we  overlook  the  facts  that 
hieniaturia  may  hi'  vicarious,  and  that  syphiliti*-  jiatieuts 
may  he  the  suhjects  of  licnKU-rhairi'  from  the  urinary  tract, 
as  well  as  from  any  otlu-r  mucous  memhrane. 

I'atiiolouy. — The  patholo«;ical  condition  of  the  kidney 
whii'h  is  tlu'  suhject  of  ha-maturia  varii's  with  the  etiolou-y. 
That  resulting;  from  renal  calculus  may  i»e  either  from 
hypenvmia  of  tlu'  kidney  produced  hy  the  presenci-  of  the 
stone,  or  from  suhse(|Ucnt  ulciTatioii  of  the  mucous  mem- 
hrane of  tin'  pelvis.  Ila'maturia  from  injury  is  the  result 
either  of  ruptured  hlood-vessels  or  of  hypera-mia.  Tlu' 
lu'nu)rrlia.iii'  from  t^out  is  usually  dept'udent  on  a  diseasi'd 
condition  of  the  hlood-vessels  and  hyiiera-mia,  while  that 
from  jturpura  lia'morrhajj:ica,  si-orhutus,  and  the  hlood 
li'lamlular  diseases  is  ijeiu'rally  due  to  the  patlioloi;ical 
comlition  of  the  hlood,  althouu;h  it  nniy  depend  upon  an 
alinormal  state  of  the  hlood-vessels  as  well.  The  Inema- 
turia  of  renal  tuberculosis  is  due  to  ulceration.  whiK-  that 
from  cancer  or  other  tumors  is  likely  to  hi'  from  hyper- 
aunia  in  the  lU'iirhhorhood  of  the  neoplasn\s.  '  The  so- 
called  endemic  luenuituria  is  the  result  of  the  hyperaunia 
produced  in  the  mucous  monihrane  hy  the  iiri'sence  of 
[)arasites. 


i 


f 


iM^lK»4in«ea!9KfK.'jUK' 


■Ws«9WiW«rrtW!W»«WWW*i:.V*^^ 


i>isi:.\sj:s  or  riir.  kii>.\i:)s. 


II 


h 


m 


Sy.mi'Tii.ms. — Tlic  I'  'iii^'tMiiioiiii'  >yiiii't((iii  is.  of  (•(nirsc. 
Moiiil  in  the  iiriiif,  wliidi  iiiiiy  It  nf  ii  (lai'i<.  -iiioUv  imImt, 
tlir  111.. 1.(1  litiiiiT  disiiitctri'iitnl.  At  (itluT  tilin-  tlir  lili'ixl 
iiii|i;irl~  \i>  llif  iiriiK'  a  tVrsli  rcil  colui',  oi'  it  iiiav  lie  Vdiili-il 
ill  clui,-.  \\\  circt'iil  tilpsci'vaticii  jiikI  »'Xiiiiiiiiati(Hi  of  tlu- 
uiinr  \v.'  Icaiii  wlicin'i'  tln'  lu'iiiiirrliai.^c  coiiics.  It  tiif 
iii'iiir  i-  alkaliiir,  tiif  ln'iiun'rliaur  is  prdltalilv  tVoiii  liic 
Maddi'i',  ami  tlic  ii!(in(l-c(.r|nisclrs  will  soon  lir<'()iiif  disin- 
toirratnl  ;  if  il  is  aiid,  thf  .•..rpiisclcs  iTiiiaiii  tlistiiirt  and 
tlu'  JK'inorrliaiiT  is  jn'oliaMv  t'nun  the  kidiuy.  If  thr 
lijodd  r(inu'<  from  tiu'  kidiicv,  it  will  lie  (•(UnpU'tily 
mixed  with  tlu'  iii'iiu'.  uidi'>s  tlic  luimn'rliaLi'r  is  (.Ncosivf, 
wlii.'h  is  si'ld.ini  tl  ••use  cxcciit  wlnTf  it  is  tfauinatic 
If  tlir  iii'inr  contains  ciots  opsti'i'aks  of' Mood,  tin-  ItladdtT 
is  tho  scat  of  tlu- troidiit".  If  the  blood  is  almost  |(iiiv  and 
is  jiasscd  jii^t  in  advance  of  tiic  iifiiic.  wc  must  look  to  tlic 
urctlii'a  ;  if  it  tollows  the  urine,  the  hase  of  the  hladdci'  is 
it-  luo-t  I'Toliahli-  soufce. 

Dai'k.  smoky.  iiortef-lookiiiLr  ufiiie.  of  a  hii:'h  siiecitic 
trravitv.  eoiitaiiiiuir  disinteici'iiteil  Mood-cofpuscles  and 
all>umeii.  is  the  characteristic  urine  in  heinorrhatre  from 
juissive  coiiLi'estioii  of  the  kidni'V.  In  such  eases  invi'sti- 
irate  the  ki.lney  itself.  It  may  1)0  eidarireil.  There  may 
he  tiiherctilar  troishle  or  cancer.  Ts  the  patient  ,t;'outy '.' 
(lotity  patii'iits  may  have  liyiiertrophy  of  the  heart,  and 
frei|Uently  de<reneration  of  arteries,  with  conse<|nent 
hemorrha-re.  the  result  of  hiifh  hlood-jiressurc*  ami  arterial 
rupture.  In  cases  wheri'  there  is  any  douht.  the  miero- 
seope  will  determine  the  presence  of  hlood-i-orpuseles  in 
tlie  urine. 

When  The  hlood  comes  from  the  kidney,  besides  heinir 
well  mixed  with  tlu'  urine,  the  jiatient  iroiierally  complains 
of  nnea>ines<.  heat,  and  dull  pain  about  the  back,  while 
occasionally  the  blood,  by  distending  tlie  iielvis  or  ureter, 


;'^l^^.JJJ^^"■g3^^i^^^:.la^<At;^.-^■■f^'W^j»^^^fJa^lafeaJe:■i«^ 


.  dt'  loursi', 
inky  colcir. 

-  t lu'  llll  M  >i I 
I   lie  \  I  iiilf<l 

tidii  of  tin- 
•>.  If  tlu- 
\-  tVolll  tlu' 
•dllH'  (lisiii- 
istiiiit  iiiiil 
y.       If   tlu' 

cnlnjili'trly 
S  i'XiH'>sivi', 

tramiiiilic 
till-  l.huMrr 
st  purr  aiitl 

look  to  tlu- 
r  liliuMiM'  is 

iii'li  siifcili'' 
lUscU's  iiinl 
•rliuiTr  from 
isos  iuvi'sti- 
TliiTc  may 
iciit  polity? 
'  heart,  and 

(•onse(|m'iit 
ami  artt'i-ial 

tlu-  mirro- 
iriuisc'k's  in 

'sides  liein<r 
y  complains 
back,  wliik' 
is  or  ureter, 


ii.VM  \-n  niA. 


.".!• 


irives  rise  to  severe  j.ain  (nepliralv:ia)  simnlatin-r  an  atla.k 
of  n-ravil  If  Willi  the  well-mixed  .leposit  of  I.I.mmI  we 
111,.?  .aMs  tlieri' ean   he  littK' douht  that    llie  hemorrhaiiv 


IS  renal 


|.,,,,  ,  ,,,si<._Tiie  i.ro,i.nio.-is  must  deiiiiid  mlirely  upon 
liu.  rliolo.;-y  of  the  heiuorrlia-v.  In  eases  of  injury  iIh' 
pr.ii:r,o>i>  is  ui^iu'rally  fairly  .>j;o..d,  unless  the  kidney  is 
di>or-'anized'.u-  <.!iier  injiirii's  have  luvn  ri^eived  of  a 
seri.m^  nature.  In  <'aneerous  kidney  the  only  liope  of 
,veov*.rv  lies  in  the  early  removal  ..f  tiie  or-an,  while 
tulKMviilar  kidney  is  LCeiierally  eomplieated  with  tuher- 
euh.^is  of  other  ori;-ans,  the  hla.hler.  testicles,  or  lun--s. 
In  Inematiiria  from  iroiity  kidney  tlu're  is  sehh.m  dan-'er 
from  mere  loss  of  l.lood.  The  pro.trnosis  in  these  cases 
must  .h'peiid  on  the  e(.nditi..n  of  oth.'r  oru'ans,  the  hlood- 
vesseis  particularly,  as  many  of  these  patients  .lie  from 
apoplexy.  ireiiK.rrhai^^e  i'auscd  hy  a  calculus  is  not  likely 
to  he  seri.Mis,  and  the  jn-o.-rnosis,  as  far  as  the  hemorrhaiiv 
is  concerned,  is  good.  Serious  residts,  howev*'r,  may  i»e 
produced  upon  the  kidney. 

Tkkatmknt.— In  the  treatment  of  hicmaturia  we  mils'- 
he  s^overned  in  a  measure  hy  the  etiolo.-^y.  Ahsolute  rest. 
however,  and  the  strictest  attention  to  diet,  apply  e.|ually 
to  every  ease.  You  will  lind  that  nniny  insist  up<.ii  milk 
diet.  I  have,  however,  found  that  thin  rice  trnu'l— that 
is,  rice-water  made  from  irroiind  rici — answers  the  hest 
purpose,  and  \  would  stron,-,dy  advise  you  to  try  it.  It  is 
prepared  hy  l.oilin.ir  for  half  an  hour  a  teaspoonfu!  of  rice 
tlour  in  a  lialf-pint  of  water,  with  a  little  salt  added.  h\ 
eases  where  liemorrha.s;e  is  the  nsult  of  injury,  it  may 
often  he  well  to  apply  leeches,  or  eui)S,  wet  or^dry,over 
th.e  hack,  while  ice  applied  over  the  ivi,non  of  the  kidn»'y 
mav  he  found  efiicaeions  in  any  case. 

Mkuicines.— A  irroat  variety  of  astrinsreiits  and  hemo- 


J£ 


3S?^jWB^Ma»wtt>«'«gy«)i':w-awip«'j«^ 


40 


nisn.tsEs  nr  the  kidsevs. 


\: 


.^tiitits  arc  iistil.  Sdiiu'tiiiiis  tlir  lu'iii(»rrliat;t'  is  iiicdiii- 
|iaiii('il  liv  |iaiii,  ami  will  rciiiiiit-  opiates  in  (oiiiltiiiatiiin 
with  astriiiL^'iits.  I'ikIci-  tlicsc  circiiiustauci's  yon  will 
tiiid  that  uiir  li'raiii  ot'aci'tati-  ot'h-ad  ami  tVoiii  two  to  live 
LTiains  ot'  hovi'i's  powiU'i-  ivt-ry  two  lioiifs  will  aiiswir 
adiiiiralily. 

Of  tlu'  astriiii^i'iits,  wlKTt,'  tio  opiati'  is  n'i|uir('<i.  ifallic 
acid  ill  tni-trraiii  ihiscs  vwvy  two  hours  will  usually  iiu'i't 
the  iiulicatioii.  In  tin.-  adiiiiiiistiatioii  ot"  u-allic  acid  it  is 
lii'ci'ssary  to  irivi'  it  at  short  intervals,  at  least  every  two 
lioiirs,  in  order  to  k»'e|i  up  its  etVeet,  as  it  is  readily 
ahsorhed  and  (|ui(l<ly  eliniinatt'd.  A  \ery  nice  prep- 
arati(»n  is  the  eoinpoiind  syrup  of  _<j:aUie  aeid,  an  old 
Hdiiihurii'li  dispensary  fonniila,  whii-h  can  he  eonihined 
with  a  little  laudanuin  wlii'U  there  is  pain.  Tincture  of 
eaniiahis  indiea,  from  five  to  ten  iiiiiiiins,  repeate<l  every 
two  or  three  lioiifs,  I  soinetinies  use  suee<'sstully. 

'riirpeiitine,  <;iven  in  eiiiulsion  with  powdered  aeacia 
and  einnanion-wati'r,  in  ten-drop  doses  evi'ry  two  hours, 
often  does  well  in  uoiity  eases. 

Of  the  ferrui::iiious  preparations,  [  have  found  the 
aiumonio-sulphate  of  iron — the  alum  iron  of  the  driiii'irists 
— the  Very  hi'st  preparation,  t;iveii  in  ahout  teii-irraiii 
doses,  well  diluted  in  water,  ivery  two  hours. 

Fluid  extract  of  ert;ot,  alone  or  eomhiiied  with  tannic 
ai'iti,  or  ertfotine  *;iven  hypoilermically,  soTiietimes  stops 
the  lieinorrhaLTc  where  all  other  reiiu'ilies  fail. 

T  would  liavi'  you  remeiiiher  that  for  the  treatment 
of  hiematuria  dei»eiidiiiir  ujion  jiassive  conirestion  of  thu 
kidneys,  especially  that  form  which  you  are  most  likely 
to  meet,  namely,  iliat  rt'sultinu;  from  disease  of  the  heart, 
astrimrents  are  not  indicated.  In  these  eases  the  liviT 
and  other  ahdominal  oriTiins  are  eijually  in  a  stat<'  of 
jiassive  congestion.     The  iiitlications,  therefore,  for  treat- 


■a-n>IH'iWofcV''.-rj-:>^V>W^«i.»«»««A<wiJ>*«i«>ai.-j*^^»^-j^-tj«.n.-.«)>ICw*»l>    ■■»li«CT!W«?Tafgl«1r»<a«>M»»iiiiV'tfil»riill>IIIIWIii<'llii|?- 


IS     JlCCdlll- 

iiliiiiiitiiiii 

von   will 

iVd  to  live 

II  ansut'i- 

•t'd.  iTiiliu! 
iiillv  meet 
:iei(l  it  is 
I'Vei'y  two 
s  reiidily 
ici'  |il'e|i- 
1,  nil  old 
eoiidiilieil 
IietUl'e  ot' 
ted    t'Very 

eil    ileileia 

vo  lioiirs, 

iMiiid  the 
di'iiii'ifists 
teii-iri'iiiii 

til  taiiiiie 
iiu's  stops 

trt-atnu'iit 
on  of  thu 
ost  likely 
till'  heart, 
the  liver 
stati'  of 
for  treat- 


Esnh'.Mir  ii.KMA'rriiiA 


41 


asinii«»«»e»i««  » 


nieiit  are  an  a-liv.-  saline  eathartie  to  iiidoad  tlie  portal 
.•iividalloii  and  deplete  tlie  eoii.iri-sted  alMloiidnal  orpiijs. 
Mild  the  freeadiiiiiiistratioiiof.-ariliaestiiimlaiits,  di.tritalis, 
.tryhniiie,  and  aleolnd.  I'mh^r  this  treatment  (he 
li..l,ioiTha,ir«'  will  eeasi-,  as  will  also  tlu'  alhiinieii. 

StroiiLivlns  -ri.ir:'^  >■■<  ''  parasite  which  is  seldom  fonnd  in 
the  kidn.'ys  and  urinary  passa.u'fs  ofman,l>nt  which  ol't.-n 
occurs  in*  lower  animals.  It  is  l.arely  possil.le  that  it 
niitrlit  produce  Inematiiria. 


("HAI'TEK    IV. 

KNl>i:.MI<'    II.KMATl  lUA. 

Kndkmk'  or  l*arasitic  Ui'inaturia  occurs  endemically  in 
many  hot  countries,  and  is  caused  hy  a  jiarasite  eiiihedded 
in  tlie  ^-lnall  veins  of  the  mucous  memhrane  of  the  jielvis, 
till'  kidney,  the  ureter,  and  the  hhulder. 

lIisi'oKY.— The  endemic  nature  of  this  form  of  ha-ijia- 
turia  was  first  estahlishe.l  in  \HV2.  l.y  (Miapotin,  in  the  Isle 
of  France.      Dr.  Bilharz,  while   studyini,'  the  diseases  of 
Kirypt,  iirst   discovered   the  cnto/.oon  that   ].roduccd   the 
ndschief.     Suhsecpu'iitly  Dr.  dohii  llealey,  while  stmlyin^' 
the  diseases  of  the  (^ij.e  of  (lood  Hope,  estal.lished  heyolid 
a  douht  that  the  eiideinic  hiomaturia  of  hot  climates  is 
caused  l.y  a  j-arasite.      Uesi.les  Ksrypt  and  the  Cape  of 
(iood  Htipe,  this  hemorrhaijce  is  indi,u;en(ms  to  Brazil  and 
the    Mauritius.       Dilharz    named    the    parasite    Dlsfowu 
iriiiiiitnhiiini  :    Dresinir   nanu'cl    it    (T//nirn,/,liur'is    Ihton- 
tnhiiis;  C'ohhold,  however,  named  it  for  the  discoverer,— 
viz.,  Bilhirzto  ILcmahhlnni.     The  last  is  the  name  gener- 

ally  used. 

it  is  a  white,  elongated,  soft-skinned,  hisexual  entozoon, 

4* 


i 


•i 


T^*srA*a*r»  s  ttnti  ww  ptf«^wig-  ■afe^w 


l#i.i**««*«WJ3IT»WWM«»9«»«MU»W^e'>'^''!'^^>*W«'*' 


I: 


insi:.isj:s  or  riii:  hii>\i:)s. 


r 


tlll'cf  or  t'lilll'  lilies  ill   Icim'tll,  and   lulnliirs  to  tllr  tri'liiiildilc 

(Hilcr  (if  wiiniis.  'I'lic  IkmIv  i>|'  ilir  niiilr  is  ((PiniMratiMlv 
thick  iiiid  >li(ii't,  iiiid  is  luipvidrd  on  its  vciitfal  a>|p(it  uitli 
a  riiiTnucd  canal  (niiiu/i.^  i/i/mi cuii/inni.^)  fur  tlic  rci  ciitiiin 
of  tlic  loiiii'cr,  delicate,  lilit'orni  female  diiriiii;'  conurcss. 
The  ovisac  dehis<'i>s  loimfiti'idinally  ;  the  ci^.^.'s  ai'i-  ahoiif 
one  oiiediniidi\'il-aiid-sevcnt_v-si.\tli  of  an  iinli  loii;.'-.  and 
arc  oval,  with  an  anterior  teiniiiial  s|iiny  proji-ction. 
'I'lu'  iie\vly-csca|ied  »'iiilirvo  is  lla>l<-slia|ied  and  eoverid 
with  cilia,  liy  the  aid  of  which  it  moves  ra|iidly  alioiit. 

Iv|•l^|,(l(i^ .  —  It  is  now  heyoinl  ijiie.-tioii  that  ihelueiiia- 
tnria  is  caused  \t\  the  |irt'scnce  oj'ihc  IHIInirzi'i  Jlii  ni'i/n/iiniii 
ill  the  small  veins  of  tlu'  niiicoiis  inenihrant .     It   is  not, 

liowevi'r,  clearly  uiiderst 1  how   it  liiids  it?   lodcement 

there.  It  I'lolialily  enters  the  liody  in  vai'i<Mis  ways. — 
heiiii;  laki'ii  into  the  stomach  with  the  water,  vcLict aides, 
or  niollusca.  It  has  hei'ii  siiii-ifi'sted  that  the  ova  may 
attach  tlu'iiif-elves  to  the  skin  of  jicrsons  hathiiiir,  Miid 
theiiee  iiiid  tlieir  Way  into  the  tissiu's.  Most  of  the  cases 
ot'ciir  hetweeii  the  aiji'es  ot'  five  and  t weiity-fivi'  yeai's,  more 
males  heiiiir  attacked  than  females. 

I'ATllol.miv. — 'Pile  |iafasite  is  not  always  confined  to  the 
mucous  iiiemliraiie  ot'rhe  urinai-y  tract.  It  has  lieeii  found 
in  the  portal  veins,  in  the  liver,  ami  in  the  veins  of  the 
alinieiitai'y  canal,  where  it  causes  heiiiorrhaiii',  diarrlui'a, 
or  dysi'iitery.  When  endu'dded  in  the  mucous  vt'iiis  of 
till-  alimentary  canal  ii  doi's  not,  as  u  rule,  pfoduce  so 
much  distui-haneo  and  disor<;ani/,ation  as  it  does  when 
present  in  the  mucous  inemhrane  of  the  bladder,  where  it 
is  found  mole  fri'(|Uently  tli-  .n  the  pidvis  of  tlu'  kidney 
or  the  ureter.  When  the  p..i-asites  are  deposited  in  <;rt'at 
numliers,  they  thicken  the  mueoiis  iin'mhrane.  and  in  this 
way  somotinus  eaiisi-  ohstruetion  in  the  ufeters. 

.I'-U'tisitie    <>v:i    ha.ve    lieeii    f^niMil   fo  f',)r!!l    tll'J    !1U'."1','US  uf 


i 


^»iB(*ip*s*^i>r. .  .\i^-,atfi», •j*;.Tx»%;s*^.v?f.'-^v-i''i«'Jw%i«:''-«i»'«- ae-a»i^^ 


^Mi 


■  lli'llliltndc 

ii|Mr;iti\ily 
ii-|ic.t  with 

•  rti  (  |itiiiii 

X   CdllLll'l'SS. 

lire   nliMiit 
lull;,''.  :iii(| 

|in>jccti(iii. 

ml  coviivtl 

•  illiollt. 

lilt'    Ilil'llKl- 

1(1  lll'll'iliiillli 

It     is    IKit, 

llMlLiClllCllt 

us  wavs. — 
vcLi'italilcs, 
i'  o\  a  iiiav 
tliinir,  iiiid 
I'  till'  cast's 
icat's,  iiiiirt' 

iiu'd  tit  the 
hvc'ii  loiiiid 
ciiis  of  the 
,  tliarrlid'a, 
IS  vi'iiis  ot" 
!ir(»dut'i'  st,i 
docs  whi'ii 
r,  where  it 
till-  kidney 
cd  ill  ijiH'at 
ami  in  this 

imi'li'iK  of 


1  ; 


n.KM  \Tl\r-  l.i. 


48 


,,    >t,„i..  iM.tli    ill    the    iMlvi-  t.f   the    Ui.l.iey   aii.l    in    llf 

"livMi'it.Ms.— The  i.atlw.irnotnonie  synipffin  is  l.ltM.d  in 
,,,„  „,ii...  intimately  mixed  wlien  it  .•-.mes  iVtmi  the 
Uidnev.  an.l  in  eh.ts  t.r  tnllt.uin-  the  mine  when  it  eoim- 
,.,,„„  •,,„.    i,i,,d.ler.       Kxeivise    ilielvaM-s    the    .,nantity    t.t 

1,1 1.   tht.u-h   the   aiiit.nnt    -f  mine   is   n..t    liUely   to    he 

.,„;,.,,„|  There  is  little  ..r  no  pain,  exeept  as  the  ivsillt 
of  violent    exeivi.e.       If  lot.-   eoiitiiuied,   aniemiu    inn-t 

'  I'limiNoSlS.  — VefV  feW  tleaths  tail  he  traced  ili  recti  V  tc 
,1,,'  etU'ets.-f  the  hemt.rrha-e,  Utld  ehildrell  seem  to  out- 
frow  the  hcniorrhairi''  temleiiey. 

"  Tiii:at.mi.:.nt.— l>r.  Ilealey  I'stahlishe.l  the  fact  that  it  is 
useless  to  trive  the  t.r.linary  astrin.iivnts  »iiii.loyed  in  other 
tonus  of  I'ueniatmi.i,  hut  that  the  parasites  or  ova  in  the 
pelvis  of  the  kidney  can  he  .le>tr..yed  hy  turpentine  and 

oil  of  male  fern.  . 

For  their  reim)val  from  the  hlad-ler  he  fomu.  iiothin.: 
,,,  .„,nal  injections  of  a  solution  of  iodide  t.f  pt.ta>simii 
coMlainiiiir  ahout  live  -i-fains  to  the  ounce  of  wafer. 


C  11  A  I'  T  K  \i    V. 

„,,,,,.,,^,.,UA-SinKims    OR    FAI,S1-;    ll.V.MATnUA  — h.kmo- 

(ii.oinMiaA. 

11  KMATiNiiUA  is  a  luiroxysiiial  disease  or  con.lition  char- 
acteri/.e.l  hvthe  passa.ire  of  hloody-lookiiiir  urine,  almost 
l.lack  or  p.".rter-colored,  and  containing  alhumeii,  hut  no 
casts  or  Mood-corpuscles.  _ 

ETiOLO.n-.— Wc  know  little  of  the  etiolosry  of  this  dis- 
ease.    It  occurs  iilmobt  exclusively  in  imiles,  ami  usn.ally 


tm6V¥t>^!61tle*»S^Vi* 


.;:S™«  «!»»'*«****«'*  ■ 


,»-.«l*»*vvl-MW^ttO*  «i;4'ta*«H»#WU:*.c^*'*.* 


44 


/'/.vAM.vA'.v  ((/•  /•///;  hii).\t-:y.s. 


I'ttw.M  II  thf  HIT'-'  n|'  Iwciity  iiml  I'ortv.  \\v\  lew  ca.'^i's 
"'(•riir  iit  liny  iiir<'  iMllin-  twenty  or  iitUT  forty.  Some  aii- 
tliors  tell  IIS  llml  it  i>  in'oiliictd  \,\  cuM,  as  tin-  |paiN>.\y>iiis 
!ir.'  ii>iiiilly  |. need,  (I  l.y  ri>|i|  ami  rcnirfciit  diilU.  'I'lic 
•  ■old  ami  cliills,  lio\vi'\»r,  are  proliaMy  tlic  r.>iilt  ol"  tin- 
fomlitioii  o|'  tilt-  lijooii,  ami  not  its  caiiM'. 

Ila-iiiatiiiiiria  is  soiiiftinn's  caiisid  liy  a  s^'ptic  comlitioii 
iiKliici'ii  Ity  tin-  iiilialatioii  of  ciTtaiii  iruscs,  fs|i('cially 
arsniiiin'ttcd  liydid.fcn,  r.iid  is  likely  to  he  pioeiit  in 
Mood  ulamlidar  diseases. 

I' A  riioi.iKiv. — 'j'lie  dixolorafioii  ot'  tlie  mine  is  caiiseil 
I>y  tlie  disintegration  ot"  the  li|oo(l-eoi'|inseles  settinir  I'ri'o 
the  liieiiion!,,l,iii  ,,1.  eoloriiiir-niatter  of  the  hlood.  I'nder 
ordinary  eireiinistanees  the  ha-niatin  of  the  hlood  heeonies 
the  iiiirnuiit  of  tin-  nrine,  hut  in  liaMnatiiun'ia  the  di-in- 
te>;rytion  taki's  place  too  rapidly  and  the  Ineinatin  i->  in 
e.xei'ss.  It  is  hari'ly  possihle  that  the  eoloriiiir-niatter  of 
the  eorpiiseles  may  escape  without  corpuscular  di-inteirra- 
tiou.  So  little  is  known  (»f  the  patholouy  of  the  diseasu 
that  it  is  dillicnlt  to  (h'cide  whether  it  is  purely  a  dis'-asu 
of  tin-  hlood,  a  disease  of  nutrition,  or  a  hlood  iilandiilar 
disease.  The  oidy  case  that  I  n'collect  iiavinir  had  under 
my  cluirir*'  was  the  suhject  of  chronic  malaria  with  en- 
larijeiiu'iit  of  the  liver  and  spleen. 

Sy.mi'TOMs. — Attacks  are  usually  paroxysTual,  wi'cks  or 
even  months  clapsimj  hetween  them.  The  passairi-  of  the 
hlack  urine  is  precided  hy  a  chill,  de]u-ession  ot' tin-  ner- 
vous system,  and  pain  ahout  the  loins.  The  urine  always 
contains  alhuinen.  hut  iK'ither  casts  nor  hlood-corpusdes. 
That  voidi'd  diirinir  the  niirht  is  Lfenerally  free  from  the 
ahiiormal  color;  that  jiassed  duriuir  the  day,  for  perliaps 
several  days,  will  he  of  the  color  peculiar  to  tlu-  diseasi'd 
condition.  Patients  are  sreiierally  cachectic,  and  often 
sutt'er  from  chronic  malaria. 


..>«;%;/.  :««:^ju...)ae»l.%JC'il«i«>■(33C'^w*u;«<e»«H»{•f«M^ 


Suiiii'  au- 
la n».\_vsi  I M 
ills.  "tIic 
lilt  III'  tilt- 

('i>ii(litii>ii 
<-|M'(Iall_v 
iiTxiit    ill 

i~  raii-cil 
•I tint;  I'vvv 
1.       I'll. I. T 

1    llCl'lHllL'S 

till'  (ri>iij- 

atiii  is  in 

lll.lttt'l'  ot' 

lisiiitfirra- 
u'  (liscasi! 

a  (lis'-asy 
n'lamliilar 
lad  iiiKJcr 

with  fii- 

Avi'i'ks  (ir 
i.iro  <it'  tlu" 

'  till-    lUT- 

IK'  always 
iriMisfU's, 
tVdiii  tilt' 
I"  inTiiaps 
•  (iist'asfd 

iiul    ntU'll 


A\.KMIA. 


Ah 


l«,,,„;vn.  IS.— Tlu'  pi-Miriinsis  is  srctn'rully  p»<»«l  s..  I'ar  as 
,1...  ,,an.xvsii,  is  ruii.vn.r.l.  ami  utlH-nvis..  is  p»vrni..l 
,.„ti,vl.v  by  »li''  '"ii.litinii  (.f  til.'  patii'iit,— that  is,  wh.th.r 
hf  is  .-iiiri  riiiir  iVnni  urirai'if  discasf  or  imt. 

'ruKAiMlAT.— As  y.t  \v»'  have  fi.iiinl  ii..  s|M..itir  fi.r  this 
.lis.as.'.  aii.l  i.n.l.al.iv  w  shall  liiid  imiir  mitil  wr  Uiimw 
,„uiv  of  its  ..ti..lo,iry  aii.l  |.atli..h.i:y.  Tlu-  nmst  su.'.vsslnl 
ttvaliii.Mt  ...nsists  ill  l.hi.iiiir  thf  liati.iit  iiii.hT  the  lu-st 
hyuii'iiir  and  dhtary  .•.■ii.rui..ii.^ :  ivst,  .iiii*t,  and  tonic 
tivatnicnt.  .■oiisistiiiii-  of  in.ii.  stryrhniin',  ars.'iii.',  vU:, 
tmitiuLr  any  or-iaiii*-  distas.'  as  iiwlirati'd,  if  juvsi'Mt. 


fMina^timimJ-:iB 


('  II  A  I'T  KIJ    V  r. 

AN.KMl  \. 

Tin:  kitln.'vs,  like  all  tho  othii-  oaMiis  of  the  body,  may 
W  til.'  siil.ie.'t  of  aiiii'inia,  an<l  must  shaiT  in  any  «r.'n.'ral 
anu'iiii.'  .•..nditioii,  sii.-li  as  chlorosis,  i.crni.'ious  anicmia, 
etc.  Wc  may  have  jirimary  anii'inia  of  the  ki.liicys  from 
..l.striiction  of  the  roiial  wssds,  the  r.'siilt  of  .liscasc  ..f  tlic 
arteries,  or  of  timmrs,  caticer,  etc.,  which  may  press  iiim.u 
those  vessels.  I'lnh-r  any  ..f  tlii'se  circumstances  the 
ki.liu'y  must  suiter  in  fuiiition  and  in  nutrition. 

It  will  he  apparent  from  the  etioh.Lry  that  aniemia  from 
ol.struction  may  he  c..niined  to  one  kidm-y,  while  in  ,t;en- 
.ral  amemia  hoth  ki.lneys  will  he  .(iiially  atU^.te.!. 

I'atiioi..h;v.— Wlu-re  the  conditi..n  is  that  of  .sreneral 
anu'iiiia,  we  should  iiml  a  pale,  ana'mi<-l.K.kiii,-r  or-raii; 
hut  where  the  umemia  is  the  result  of  ohstriictioii  for  a 
loiiir  period,  we  sliouhl  expect  to  tind  the  or^'an  atroplii.-.l 
as  wi'll  as  anivmie. 

Symptoms.— There  are  no  special  sympt.»ms  to  indicate 


I 


_,-_.-i' 


■H 


ref- 


ill 


insi:.isns  i,r  Tin:  a7/».va').v. 


tlli-.  r..||i|iti(i|l  :     lillt    it'    lIllIT    lir    il    Illlllnl'    ill     till'    lllMlnliirtl 

aihl  il  iiiiiik.il  l.-sfiiiMLT  "t"  tln'  «|iiiiiitify  ut'  uriiH-  willmnt 
iilliiiiniiiiiii!!  mill  iinirji  sutnitiiiir.  wi-  niiiv  .iiiil,Lr>'  Hial  llir 
kiiliiiv  is  siiU'iiiin;  iimii  Im-k  nf  niitritiuii.  Wlnrc  uiil\ 
Mill'  killing  is  iiiM.Kiil.  tin-  pi'iihiiliilitiis  inc  tliat  tli.iT  w  ill 
III'  no  iiiijii-iitiiiii  ul'tlir  ruiiilitiiiii. 

I'|Iim;\MS|S. 'I'llC  |irilLriH)'is  l|t'|ii'l|lU  II|mi||  tin'  flMlSf.         ]{' 

till'  atiifiiiia  \<r  tlir  ri'Hiilt  ut'  a  laiii-rnms  «a(lit\ia,  tlir 
prnirndsis  will  \>r  Imd;  ifnl' ililun.sis,  it  will  l.r  tiiVMialilc. 
'ri!i:\r.Mi:Nr. — Tln'  tiiatnuiit  iiiii>t  tli'|iriiil  ii|iiiii  tin- 
itinlu^fv.  III  a  iri'iicral  aiiiiMiiii'  ••iiiulitiiiii  uc  imisl  rely 
i>ii  lifiirral  ticatiiiiiil.  In  >|ii"ial  anaemia-  ..f  tln'  kiilmy, 
— that  is,  wliiiT  lliiTc  is  (ilislnntioii — ih.'  indiciiiii.n  i»,  nl' 
rtiUisi',  to  niiio\c  tin-  cailsi'. 


(11  A  i'TKK     V  11. 

ii!si;asi;s  nr  tiii;  iiknat.  iii.nuit.vi:s,sKi,s, 

Till-:  I'l l-vt'ssfls  ot' till'  kidiu'vs  ari' siiliji'it  to  tlic  >aiiK> 

ilisiasi's  as  llioso  ofotlii'i-  parts  oftlic  ImmIv.  In  tlic  kiilm-y, 
liowcviT,  llu'v  arc  of  more  intciTst  to  tlic  |iatlio|i.^-i>t  iIimii 
to  the  clinician,  as  it  is  cNtiviiicIv  dillicult,  ami  so|||c^inlcs 
cviii  iinpussililc,  to  diatrnosc  their  exact  condition.  It  is 
iievirtjicless  iiii)M)rtaiit  to  know  that  ohsciiic  syni|itoins, 
and  |iain  in  oi-  Iicniorrhairc  tV'  Mic  kidiicv.  may  dc|icml 
uitoii  a  itatiinloi,'ical  conditio  •  renal  hlood-vessels. 

l)E(iK.\KI!  OF    AUTEIIIKS 

The  causes  that  proM..  atheroma  or  i-alcan'ous  dcifeii- 
eralioii  ot"  tlie  rt'iial  arteries  are  the  same  as  those  that 
|»rodiice  tri'iieral  atheroma  of  the  otiu'r  hlood-vesselrf. 
W'hetlur  the  leiial  arteries  are  as  suhject  to  atheromatous 


~::rnrx^vrs-rTin^,-iSK^-rf^r^^i^^»,msKMmmJ2^^ 


lilllSf.         W 

lu'xi:i.  llic 
tiivoialilc. 
ii|M)ii  the 
III  list   ii'ly 

ir  kiillKV, 
llinll    i»,  iif 


1  tile  >iiliit' 
K'  kidiifv. 
i>Lri>t  iliMii 
■iiiiHfiiiifs 

nil.        It    is 

yiii|>tuiiis, 

l_V  <l»'l.clli| 
1-vc'ssds. 


US  (it'irt'ii- 

liiisr  that 

xl-Vi'SSels. 

M'oiiiatouf* 


Disr.Asf.s  or   Tin:  /;/.vt/,  iii.noii.VHssrJ.s. 


II 


.ia^r;i<iw«.'M  »•  ■' 


.h'lr.lUTiltiMli    a.    th.'    nlli.r    iirtrlirs    is    V.TV    .itl.;-ti..|iill.U'. 

Wliilf  it  is  II. .t  imiH.ssilih'  \nv  liir  niml  iiit.  ri.s  \n  !..■  ih.- 
siiLj..  t  »\'  atli.r.'iii;!  iii.h|.fii(hiitl.v  ..f  ii  ^'I'lu'fal  hiiiiihir 
(•oti.litioii,  it  Im  pioliahly  v.tv  s.  Iih.m  th.'  cast-. 

Wi-  tiiiil  tin-  niial  artciifs  tlic  .-iil'jcrls  nf  alh>r.>iiia  in 
•TdUtv  ami  ihniiiiatif  [latii-iitM. 

'I'll.'  hn'iiialmiii  in  jT'iiity  palii'iitH  i«  im  .h.ulil  ..ftrii  dwinir 

t..  this  caiiHi.     At  th.'  Ham.'  tiiii.-.  th.T.-  is  ii.i  |H.:.sil.h'  way 

olairiviiiLT  nt  .'.Ttaiiity  as  to  tli.-  »'ti.ih>,i.'y  of  a  hn'iiiatiiiia. 

W.' >hall  s.'t'  tlial  this  coll. liliMii  of  th.-  art.'ri.'s  phiys  an 

iiii|.ortaiit  part  in  aln.i.hy  ..t'th.'  ki.hi.'y.      In  "l,!  |M.rs..ns, 

at  |.n-,t-iii..rt.iii  III.'  ki.liu-y  is  ..rt.'n  t'onntl  small  from  alro- 

|.li\,tlu'  ri'siill  of  iiiilnliv.'ili>tiirhan.'.'  .'aiis.'.l  l.y  a  h'ssoi- 

iii'.!' of  thi!  caril.r.'  of  th.'  art.'iii'S  fr.mi   ath.roina  ..r  .al- 

.•ari'..us  (h'i..)>its.     T'>"  vt'ss.'ls    aiv    also   v.tv  fiv.|i!.'ntly 

athi'i-omatoiis  in  th.'  small   tri'unular  khliu'V,  hnl    in  this 

install. •<■  Ih.ir  .•on.liti.>ii  is  not  th.'  .-ins.'  .>f  th.'  small  siz.' 

of  th.'  origan. 

ANKUUISM. 

'rh.i'f  is  no  reason  why  we  may  imt  liav.'  an.'iiri>ni  of 
th.'  renal  arf.'i'y.  A'^  »  matt.T  of  fact,  w.- .lo,  .•.•.•a>ioiially. 
at  ii.ist-mortcms  timl  an.'urism  ol"  this  vessel.  It  is,  as  a 
nil.',  .lis.'overed  .mly  after  .h'ath  ;  since,  mil. 'ss  .|uite  larir.'. 
it  woiihl  he  ini|M.ssihl.'  to  .liairn.'^^'  it  ihiriiiir  Iif.'.  I'ain  in 
th.'  ki.liu'y  a.'c.tini'ani.'.l  with  laematnria  an. I  a  pulsatiiiLr 
tum..r  woiiM  c.Ttainly  justify  -i  .liairnosis  ..f  anenri>iii  .>f 
the  I'.iial  art.'i'y. 

EMBOLISM   .AND  TIII'.OMHOSIS. 

It  is  imiDssihIe  to  ascertain  the  fre.inency  of  emltolism 

in  the  renal  art.-ries  as  comi>are.l  with  emhoHsni  in  the 

(i-ain.  for  instance;  sin.'e  it  is  sel.l.mi,  if  ever,  possihle  t(» 

.lia<rn.)se  such  a  coii.lition  of  the  renal  arteries.     Frein  the 

large  si/.e  .)f  the  artery  uri  compared  with  the  organ  itself. 


1 
J 


»f ' 


48 


7)/.s7;.i.s7;.v  or  riii:  a7/).v/;jx 


111 

w 


<t  i-  iiufural  to  sMpiiost'  tliiit  it  is  ot'tcti  tlii'  sulijcct  nt"  cm- 
Itdlisiii.  There  is  IK)  (l(iMl)t  tliiit  iil»scess  of  the  kiiliiey 
often  results  tVoiii  this  eoiiilitioii.  Wliere  :i  hirtrt'  ''r;iiieh 
of  tlie  iirterv  is  olistntrted  ii  iriMieral  iiejihritis  miylit  result, 
■  or  iiifaretioiis  take  |ilaee.  The  etioloiry  of  eiiibolisiu  of 
the  I'eiial  arterii's  is,  ot'eoiu'se,  till'  same  as  that  of  I'laho- 
lisiii  oceiirriiiir  in  other  origans  ;  aeiite  eiidoearditis,  athei'o- 
liiatous  <K'<;eiieratioii  of  tln'  eiuloeanliuiii  or  of  the  valves, 
or  vet^t'tative  detaelmieiits,  iniLrh'  'n-  the  cause. 

Thronihosis  is  <;enerall\-  the  result  of  injury,  atheroma, 
or  invasioi,  of  the  arti'ries  liv  intlaminatory  conditions  of 
other  oruMin.  Throinhosis  of  the  renal  veins  is  likely  to 
occur  from  injuries,  such  iis  hlows,  falls,  iH'iictratinir 
Vvounds.  from  the  coiiiiiression  of  alxloniinal  tumors,  or 
from  ir  .laminiition  extcndinu'  from  otiier  ortjans.  One 
result,  _io\vcver,  that  is  likely  to  follow  tliromhosis  of  the 
veins  is  jiassive  «"on<restion  of  the  kidneys.  If  tlie  other 
causes  that  ]>roduee  passive  conirestion  of  tin.'  kidneys  can 
l)c  eliminated,  it  will  he  iiiir  to  suspect  thrombosis. 


*|l 


k 


ciiArTKK  virr. 

IRIXE. 

UiuNE,  the  secretion  of  tlie  kidney,  consists  normally  of 
a  solution  of  substances,  ortranic  and  inor<ranic,  the  result 
of  tissue-metamorphosis.  It  is  a  transparent  tluid,  of  a 
pale  Uinon-ydhnv  color,  of  acid  rcacti<in,  huvinsi  u  specific 
c.avitv  rauiiintr  from  101.')  to  10-2"),  and  is  jiassed  in  (|nan- 
tities  averairiniT  frotn  forty  to  fifty  ounces  a  day.  Kaeh  of 
these  characteristics  is,  however,  subject  to  variation  botli 
in  health  and  durintr  the  proiirress  of  diaertse.  The  jirin- 
cipal  organic  constituents  are  urea,  uric  acid,  xanthiii, 


•T^rn^Ts'Js^f^^tnssr' 


i_H'ct  (it  cm- 
tlic  ki<lm'_v 
irtrt'  liniiicli 
liii'lit  rt'sult, 

lllbolislll  nt' 

lit  of  »'m!)i)- 
litis,  atlu'i'd- 

'  till'  VillVi'S. 
•,  atlHTdlUil, 

mditioiis  ot' 
is  likely  t(t 
|ic'iictratin<r 
tiiiiKH's,  or 
;ims.  Olio 
hdsis  of  tlu' 
If  tlu"  otlior 
kidiK'V.s  am 
Jtisis. 


iioniially  of 
c,  tin."  ivstilt 
t  lluid,  of  a 
iii(  u  spt'citic 
iv(\  ill  (|nan- 
V.  Kacli  of 
nation  hotli 
The  prill- 
id,  xiuitliin, 


nusK. 


49 


kivatin,   kn.atini.u.,  oxali."  arid,  oxalnri.-  a.id,  l,iH>..n. 
.,.,•,,1   vtr      TIk-  iM..n:aHir  coiistitucllts  collllM-lse  sulpliunr, 
i.vdro.hlorir,  a.i.l    idio^plioriy  acids,  sodimii,  i.-.tas^uiiu, 
;,iiminniiiiii,  iiia,<riH'siniii,  ealriuiii,  I'tc. 

y',„7,;,/;/,/._Tlit'    nriiu-    may  Uecom.'    turl.i.l   wlim   tlir 
„„„„„t  si-rn-trd  is  small  in  -["""tity  and  from  tl.r  fivs- 
^,,„,,    „,•   ,„,it.s.   tlu'   i'artJiy    liliosidiafs   of   .alrmm    and 
,„;,.,,H.i,im,or  the  mixed    urates  of  sodium,  i..,tassium, 
..al'ium.ai.dmaumesium.      In  the  female  it  is  ottm  eloudy 
i,,,„„  admixture  with  va-i..al   s<..'retions.      None  o     the 
al.ove  eMiiditions  are  of  necessity  al.n..rnial,  althuu-li  tli<. 
,,..,..istent  presence  of  phosphates  may  indicate  an  excessive 
.'ikalini.v  which  mayre.,nire  treatment.      Iheturudity 
inuv  In.  cause.l  hv  admixture  with  the  urine  ol  hlood,  pus, 
,n„cu>.  or  tat,  ..;  may  he  the  result  . if  a  decomposition  ..t 
,1,..  urine  i.  the  Idaddcr.      Sarcime  are  occasionally  touud 
i„   ,1,,.   mine,  reiiderinir  it   turhi.l   when   voided,  and  set- 
tli„.  as  a  whitish  riocculent  .lepo.it.     The  urine  may  coii- 
taiiMuither  pus  nor  mucus,  the  turhidity  heiii- due  entire  y 

to  the  sarcime.     Tliey  prohahly  tind  their  way  int..  the 
nrinarv  tract  hv  means  ..f  unclean  catheters. 

r„/„V— The  e.dor  of  the  imrmal   uniu'  varies  trom  tlie 
,u,,rlv  coh.rless  urine  that  tolh.ws  the  iii-esti..n  ,.f  a  -ivat 
nuaniitv  ..f  li.iuid  ('"•'•/'"  /'"'">■),  t..  th.'  .lark  wme-yellow  o 
tlH"  eoiu-eiitrated  urine  passe.l  in  the  m..rim.-,  ..r  hy  sueli 
as  have  an  excessive  acti..n  of  the  skin  or  in  wh..m  the  re- 
spiratory exhalations  are  .irreater,  thus  reheviii-  the  hh.o. 
of  much  .)f  th.'  watery  ex.-retion  whi.-h  is  usually  passe.l 
l.v  wav  ..f  the  kidney.     The   normal   ..olorin-matter  ot 
the  hlo...l  is  ur.dulin,  whi.-h  is  f..rme.l  imlire.-tly  m  the 
liver  from  haMilT.-h.hin.     The  nrine  umlei-oes  .•han-e  m 
e..l.>r  f..ll.>winir  the  use  ..f  .-ertain  .Iru-s:  ,.;/.,  rhul.arh   a 
d.'cp  vellow  •,  santonin,  -ohlen  yelh.w;  senna,  br..wnish; 
earhoii.-  acid,  tar,  or  creasoto,  hn.wn  or  bhuk.     Blood  will 
c       d  8 


?s;?i; 


'r-«';,-5'iUff.i'-'.'ff  •SI-''* 


n  ^  .  •fl?'*-*^*'^'' 


tW  " 


50 


I)Isi:asks  or  r/ir:  i\ii).\/:ys. 


ll  ' 


cnliii'  til*'  uriiii'  ri'il,  or,  wIhti'  it  is  <lisiiitt',i;ratt.'<l,  ti-ivi-  it  n 
lir()\viii>li  or  I'oi'tcr-foloird  iiiiiiraraiict'.  In  jamidici'  tlio 
l»iliarv  inattri's  u'ivi'  risi'  t(»  various  tints,  from  dark  vrllow 
to  Itrowu  or  i;rccii.  Tiis  or  fat  will  iiii|>art  to  it  a  (•rcaiiiy 
color.  |)ial)c'tic'  iiriiu'  lias  a  rliarartoristii'  ii^'lit  tiivonisii 
color. 

/iciirtioi). — Tlif  n-actioii  of  normal  uriiii'  is  acid,  caused 
\>\  tlic  jiiTsciicc  of  the  aciil  pliosphatc  of  sodium.  Somh- 
time  after  iH'iuir  voided  the  contained  mucus  and  or<;'anie 
coiistitui'iits  decompose,  and,  actinir  upon  the  urea  a-^  a 
ferment,  cause  the  proiluction  ot'  carlxmate  of  ammonium, 
which  i::ives  to  tlie  urine  an  alkaline  reaction  and  an  ani- 
moniacal  odor.  It  is  important  to  di.-criminati'  lu'tween 
uriiu'  I'ciidci'ed  alkaline  hy  decompositioii  after  heiiii'' 
voided  and  that  which  decomposes  in  the  lila<lder. 

Tile  ve^vtaMc  ami  mineral  acids  will  make  the  urine 
more  acid.  The  urine  voided  several  hours  aftei'  meals  is 
often  found  to  he  alkaline,  for  which  circumstance  several 
theories  have  been  advanced,  tlio  most  proi»al)U'  of  w  hich 
is  that  ot'  Kol)erts,  who  believes  that  it  is  due  to  an 
admixture  with  the  Mood  of  the  alkaline  elements  k['  fond, 
which  ai'i'  lai'irdy  in  excess  of  other  elements. 

S/>ti-ilii-  (ii-iirHi/. — Till'  specitic  trravity  varies  in  health 
tnuu  inl,")  to  lO:i.').  It  may  in  Krin'i  /mtus  he  as  low  as 
1(1(1.").  or  less,  in  healthy  persons,  while  in  warm  weather 
and  when  tlu're  is  a  fri'c  action  of  the  skin  it  may  lie  as 
hiuh  as  l():iS.  or  even  1(»:}0,  in  wiiicli  case  the  urine  will  he 
small  in  amount.  It  will  depend  i^reatly  upon  the  amount 
of  fluid  imrested,  heart-pressure,  mental  emotion,  condition 
of  the  stomach,  or  activity  of  the  howels.  The  specific 
ii-i-avity  ot"  the  uriiu'  is  of  irreat  importance,  hotli  for  the 
(iTaii'iiosis  ami  for  the  pron'nosis  in  disease  of  the  kidney. 
We  mav  look  for  a  patholoirieal  <'ondition  when  the  spe- 
cilic  u'ravitv  is  low  and  the  urine  small  in  amount,  as  in 


^1 


J 

1:1 


vr;^;i!5Sg^v«v#s.\if!i&^s^7i&i«vAjS,ai!(*}to't^^ 


fA'/.v/;. 


f)! 


,  li'ivc  It  i\ 
iidict'  tlu- 
I'U  vclliiw 
a  iTciiiiiv 
ii'i'i'i'iiisli 

(1,  caust'il 

II.       Sollli' 

il  (ii'ii'anic 
iria  a-^  a 
iiiioiiiuiii, 
<l   an  aiii- 

lll'tWCl'll 

■r. 

lln'  uriiif 
I'  iiu'als  is 
(•(■  st'vcnil 

(if  w  lllrll 

liu'   t>i   an 

tS    dt     t()M(|, 

in  licaltli 
as  low  as 
n  weather 
uav  lie  as 
ne  will  lie 
le  amount 
eonditioa 
le  s|(eeitie 
th  for  the 
le  kidney. 
II  till'  spe- 
nnt,  as  in 


„.U,,i,is,  Of  when  It    is  hi,h   and   the   amount   voided   is 

lar.T.  ;is  in  diahetes  m*'llitus. 

f    nn.ke  the  s,K.eiti.-  ,n.vitv  of  value  ,,yiK..noM.^^^ 

,,iU,,e,u.eessarytotaketha,..t'as,,ee,men.ron,aeoll.- 
tion  of  nmu.  for  the  whole  twenty-tour  hours. 

,^,„,;.,_The    avera^.    un.ount   ot    urn.e    ,  ^.d 
„vu.tv-iour  hours  is  ahout  tiny  outuvs    hut   varte.u.tU 
',;,.,,-,,.  of  the  skin  and  howcls  atnl   the  amount   o 

,     i,„e',ed.      rathoh.,h-ally,  the   an>ou..t  o.    urn.e    > 
:;;„,,,U.   i,.ereased   in    diahote-,   ,n    hyster.eal    or    oh 

--^=''''^^-r^:;:t.;;;:x^ 

;;rrr:;:;:  .;:;■  :n.:;:;..-iti.  th..  i.  di.ni.d.in..i ... 

:  eXm;\uHl  when  the  dituinution  in  amont.t  ..  a...o.   - 
;:;-edwhhah>wspecitie,ravity,itn.eansad.,n.,u.hod 

^•^O:;!:' ^n-^'ollor,  whu-h  has  hoett  deserihed  as  swoott.^^ 
or  unmumcs  vat'ies  i..  in.e,,sity  with  th.  atnonnt  o    e.,n. 

.entvation   of   the   nritK.      Wlu-n   d.-otuposed         h  > 
atntnotnacal   odor.      Cortain   dru>rs   mq-art     oh,    turn 
,,,,,,teristie  odors,  as  do  also  ee.1a,n  vep.tal   ..       1 

,.,„ti,u-  -ives  it  the  odor  of  vh.lets;  euhehs.  eolK"'"  •  '^"'^ 
!:;;dal.v^od  on  i,n,.art  to  it  the  odor  ,eeuhar  to  thctn- 
selves,  as  does  also  asparaiTUs. 

CHEMICAL    COMPOSITION. 

Tho    n.Uowin..^   table,  eopied  frotn    Hotf>nat>   and    rit/.- 
,,,nn,  .ives  the  iu-inei,.al  solid  eonstituents  ot  nortnal  unnc 

and  the  average  (luantity  exereted  : 


mf^s^^^^a^^^ 


>i<«Jti.<i'"jf*C*»"»^' 


f 


ill 


52  i>isi:.\si:s  of  tiii:  a7/>.y/;j.v. 

iiriiiiniii-  I'rr  i  cut. 

Sdiil" "10        Til  4.:!       -4.0 

frfii :in       4(i  I'..".     --:!.'.' 

III.-  mill 4--     .s  .{)■',        .ti.-. 

ciiiMiid.- 1(1     -I;;  .7        .s 

Kniitiiiiiii^ .")    •   1.0  .li:ii'i       .W2 

llipl'iiiir  iiciil ii—  1.  .ti'J         .(m; 

K:irt)iy  |iliM>]iiiiitcs U-  \:.\  .117         .(i,s 

rii..>|.ii.Ti,'  iici.i 1.'..".     :;..'>        .w      .'j-j 

Sul|iliiii  ir  iu'iil l..'i       2,.')  .Ir,         ,17 

Ki'oiii  till'  iilidVi'  talili'  \vi'  SCI'  that  llic  imi-t  iin|iiirtaiit 
(if  till'  solid: — that  is.  thosi'  ('Xci'i'trd  in  ii'i-catot  i|Uaiitit  v — 
ale  iifra  ami  chlofidcs.  the  otliffs  licin^-  sn  small  in  <|iiaii- 
titv  that  thfii'  |ii'c>riicc  or  aliscucc  has  init  little  ctrctt  ii|piiii 
the  s[H('itir  u'favitv  tit'thc  urine. 

nlMiA.MC    ((iNSTniliNTs. 

f'l-i'i   is   the   iihi-t    iiiiii'U'latit,   iieitii:-   jiassed    in    lai'ii'est 

aiimunf  of  any  of  the  solids,  and  its  aiiseiiee  indieatinu" 

iii'a\i' distufhaiii-e  of  the  u'eiiei'al  economy.     The  amount 

of  urea   passed  in  tweuly-four  houis  varies.  aeeoi'diiiLT  to 

e.\el'ei-e.    t'ooil.    oeellliatioll,    etc..    iVom    t\\i>    llUlldl'i'il     ami 

fifty  to  five  hundfed  and  tit'ty  iiTains.  l)e|ieudinir  as  it 
doi's  upon  the  activity  of  llu'  liver  and  thu  amount  of 
tissue-waste,  it  will  vary  with  the  amount  of  nitrogenous 

food  iuLl'ested. 
It  is  iiicri'asi'd — 

1,  When  much  nitfo<renous  food  is  taken. 

2.  Fn  conditions  of  the  livi'f  in  which  thefi'  is  incivased 
activity. 

'.].  In  the  I'arly  sta.ii'es  of  disi'ases  in  which  there  is 
increased  activity  of  cells. 

4.    Wliere  liai'd  muscular  work  is  performed. 

').  FeviM'.-'.  (It  is  a  (|Uestion  wlietlier  in  ceases  ot' fevers  it 
is  due  to  increased  metamor]ihosis.  or  to  chanii'i's  in  the 
food  from  failure  to  assimilate  at  so  hitrk  a  teiuiieriituro). 


'M,U  I 


T!:^;ei5-?*Ji?K3SS??35m7^s:JF?3!SE^,^ 


iitish:. 


:>:$ 


lit. 
i  i; 

.O'l 

> 

.(Mi 
.(IH 

.17 

illl|iii|-t;illt 
UillltitV  — 
I  in  •|iiaii- 

tl'l'tt     lllMlll 


II  lai'ii'ist 
mlicatiiiL;" 
I'  aiiiiiiint 
Di'diiiii'  ti) 
(li'L'd  ami 
liiiir  as  it 
iiKUint  of 
troi^oiious 


im-ivasud 
1    tluTc   is 


•t'fcvrrs  it 
:rs  ill  tiu' 
penituro). 


,;    |„.ilalK.t>.snu.llin.sa.Hl.lial..t.si..si,.i.lus 

tr  in  Unnirinir  al»iut  laii- 


„,,.  ,,,  yvn^huy  tl.r  iiMiMnal  !un..nn 
is(liniini>li<'<l  t'orniatioii  in    ' 


tlii'li\HT,«»r  tlu'ivis  ilimini-livd 


^.xnvlinn  in  tlu- ki.liu'.v. 

1     Wli.n-tiu.  i'='tiH.tisat,v.t,nnnnlk.l,..t.   .1  Ut,n 

.;   W1H..V  tlH..v  isa^ln-i^l.   .■undition  ..,•  a  tun.t.onal 


:1    Wlu.>vtlK.,visdis..as.oftlu.Uidn.v,n,..rU.nn.u,,l. 

^■'ui^!^' fs  di>.as>M.ould  not  h.Mlia^nosM  fro.n  tin.  a,n.^^^ 
.,.,,,;  ......,.dJu.tJ<.u.win,tl...dis...s..tol..,.,v^^^^^ 

.H„u,us!u.d  .Nr,vtion  of  uiva  wonld  .•on-.^...n.t..  tl.   d,a;:> 

,  Lis,  and  tlu.  :unou,.   .x..M.d  would  ,nv  son,..  ,d.o^^ 

he  oxtont  of  kidm.v  involved.      If  vou  know  that  th.  In. 

^"^.^         ..  .  .    , ui...  ..,,,1  fn.d  the  normal  amount 


and  other  tissues  a,v  lu-ahhv  and  tind  tin.  u 

,t-n,-oa  present,  you  tnay  he  ......tain  that  the  d.sea..  ot  tlu 

kidnev  is  not  very  ext(.nsiv(..  . 

4  In  ehronu.  diseases  where  tissue-eha.,^e  ,s  ,,n,,a,re.l. 

5  T„ehl..rosisaml  other  ansvinnis.  _ 

Of  late  the  suhjeet  of  tlu.  ahsolute  and  relatnv  a,u.m,.t 

,,.,„.^.^,  ,,,l  .laorhles  ,..-ese,.t  in  tlu.  urtne  UMatu...  .4  ^^ 
ston,a.hhasreeeive.leonsiderahh.  attent.on.      Ihe  e  ha 

not  '-oen  a  sutHeient   numher   ..f  ...xam.uatu.ns  as  y     to 
"t^^hlish  a  rule  tor  dia,n..sis  ;  hut  it  w.>uld  seem  a..eonhn, 

I  ,,,„,,,,  that  the  ttrea  is  i.u-reased  and  the  <hlort.les 
are  diininishe.l  in  caneer  of  the  stomaeh 

Considering^  the  n<.rmal  ,.n»iK>rt,on  oi  ut-ea    ..the  .hh>- 

Pides  to  he  a;  "2  t..  1,  Ih.uveret  of  Ly..ns  tou.ul  in   eatu-er 

;^Jst.unaeh  the  relative  ,-ath.  to  he  ^H..l:  tin.  ts>o 

parts  of  ut-ea  t.,  ±4  ,arts.,feldo.-ides;  hut  lunmelor^^^ 

of  Brussels,  who  has  .triven  the  suhjeet  eot.stderahle  attui- 

tt     a-utnes  the  tu.rtnal  an.out.t  of  urea  to  h.  twenty-hve 

nu nines,  and  li.uls  that  when  it  is  redueed  to  ten  .ratntues 


V^gt«»«;»iAs*o*JW;=K*'** 


r" 


^- 


54 


DisKASEs  or  Tin:  i<n>.\/:is. 


&: 
d 


I- ' 


jur  ilii'iii  ill  ii  ciiM'  (ifirastnc  disciisf  it  iii;iv  lie  sat'fly  cou- 

siililcil    railrrn.lls.        It     will     prolialilv   l>c   I'iMIIkI    to  <ir|ic!l(l 

iilinii  the  aiiioiiiit  lit'  voiiiitiiii:-.  W'licii  tjiis  is  t'xci'.s^ivf 
thr  ell!. .rides  will  iiatiii'allv  lif  (iiiiiiiiisliiMl.  'I'lic  siil.jcct 
(Ic^crvcs  cai'diil  stmlv. 

I  i-ir  .\,nl  ami  /'I'ltts. — Aiiv  increase  in  the  aiiKiiint 
present  (it'  these  ediistitllellts  is  iisiiallv  (lile  III  the  same 
itiiiditiMii  that  causes  a  diiiiiniiticii  of  urea.  'Phev  are 
siiii|)l_v  urea  iiiiiierteetlv  o\_vi:-eiii/i>d.  I'ricaeid  is  raroly 
I'Xercted  tree,  lieiiiiT  ,ir<'nerally  in  conilmiation  with  po- 
tassiiiiii.  soiliiiin,  and  aiiiiiioniiiiii,  and  also  with  inau:iie- 
siuiii  and  calciuni,  loriiiiii!:.-  wiiat  are  known  as  the  mixed 
urates.  We  iiml  an  incri'ase  in  uric  a<id  or  iirati'S  from 
increased  in<festion  o1'  nitrcureiioiis  food,  where  too  much 
Work  is  thrown  on  the  diijestive  system,  the  food  hcintr 
poorly  digested  in  the  stomach  and  the  liwr  heiii<r  unahle 
to  pi'rform  its  work.  In  other  words,  it  nu'ans  an  imper- 
fi'i-t  oxidation  of  nitroi^eitous  tood.  We  find  this  in  i^outy 
patients,  in  chronic  hroiicliitis,  where  tliore  is  ohstruc- 
tioii  to  the  Venous  system  and  passive  congestion  of  the 
liver,  in  heart-disease,  and  where  outani'ous  rospiratiun  is 
diminished,  also  in  the  insane. 

IJesides  the  ahove  eoiistitiieiits  the  urine  contains  small 
<|Uantities  of  liippurie  acid,  wliieli  is  formed  in  tlii'  hody 
from  proteids;  kri'atinine,  derived  from  musele-kreatin, 
increast'd  in  fevers,  pneumonia,  etc.,  and  diminislied  in 
ana'inia  and  wastintr  diseases;  and  xanthin  :  all  of  which 
are  simjily  less  conniletely  oxidized  products  of  tissue- 
ehauijes  than  un-a. 

IMiKiiAXIC    COXSTITrEXT.S. 

Of  the  iiiorifaiue  constituents  the  most  important  are — 
1.   Thf  C/doridiS. — The  cldorides  in  human  urine  con- 
sist almost  exclusively  of  chloride  of  .sodium   with  a  very 


.v.wajK:sm'Cj/-U;^'^v^-<i^'i^v«?:.fcji;cife:&;s- 


iiiM 


riiisr. 


i)<) 


<iifi.'ly  I'oM- 

tl>    <1('|IC||(1 

t'\rf»ivf 
lie    sllliji'ct 

<'    aiiKiiiHt 

llic  saiiii' 

Tlii'V  are 

I  is  rarely 

I  with  ]io- 

ll     lllilLTIH'- 

iiic  iiiixfd 
rati'S  iVoin 
too  imitli 
r)o(l  lifiiitr 
n<r  uiiahK' 
an  impiir- 
s  in  ijouty 
r*  ol)striU'- 
oM    of  the 

•iration  is 

ains  small 
tho  liody 

le-kreatiii, 

iiiislu'd  in 
of  which 

of  tissuL'- 


tant  are — 
irine  con- 
ith  a  Very 


.,nall  .n.ount  of  chloria "  ,.otas.ium      ^"'''"'•'•!',  "'|,^;; 

,;;;;;;!  ,;.,,sal.outon.-t;.urtl.  of  .lu  total  soh.lsotlu.aUh> 

,     .        ,1 u  f.i^tf  to  till'  st't  rctioH. 

"U    ;      ,;,vas.l    in    Hri,hfs  .liscas.,  in   .ln> Wt.s,  .n. 
,,,    .    l..,;.vo..aa.rpuroxysn.sof.;™     K -l""'"-' j 
„  ,,.,  ,.„,,.  •„  ,t  r.st,  an.l  in  pncnnonn,  and  a     . 
;;,i:,-K.  ,lis.as.;,  .s,..'ially  those  ao-on.i.anu.a   1,    ..,on> 
c.NU.lati-ns  or  watery  passa.ires.  _ 

..     '/•/„    rhos,,h>hs  are,  of  two  varieties,  the  ea.tl.N  an.l 
th:alkaline  ,hos,.ha,es.     The  earthy  ,.h..s,hates  are   ho.e 

re  leiuia  an.l  nUne^iun..     >'' --^''-''^    \'    '^lin    nt 
,,,,,,,. I   in  sohuion,  hut   iheyare.hr-'teaa.  >e.hin.nt 

^■'•'-:;::;:;;;;;;:\;th;:  earth.  ,.os,.ates  is  oi.^^^^^^^^^^^^^ 

,,,•  i.o.u.,  ..ste.miala.'ia  an.l   neket.,  m  n 

,,,,l,,i,i.,  i„  .liseases  of  the  nerve-.-ntres  an.l  atte,  ,ir.  ■  t 
m'ltal  Strain.  Koo.l  an.l  .Irink,  the  latter  es,ee,alU, 
iiK  Ti-a-e  the  nhosnhates.  .      •      n     i  ,. 

,       1  flw.v  Mi-e  for  the  nn.st  part  .h'rive.l,  a  Muall 

;::;;^:  ::;:;hi;.:  ."ive.uv.nn  ;h.;^aisinte,^^^^^^^ 

'    -.  u.  .u.l  museular  tissnos,  so  that  inrta.nn.ation   t..e... 
;:::::  i~l  activity  of  the  vital  processes  w..iihnav.,r 

the  eii.nination  of  a  -reater  ani.mnt. 

The  ..ther  inoi-anie  constituents  are  ot  s.>  1  tth.'    1.   ual 
■  .  th.,t  we  ^hall  eonsu.ne  no  further  tune  m  their 

importance  that  ne>iuui  ton  ,  »•  u.>..lc  Tv<on 

con.i.lerati.,n,  referriiitr  you  to  the  works  ..t  Ikak,  In. on, 
Koherts,  an.l  .^hers  up..n  the  suhjeet. 


!'i'K/ci'^^->'"'T."-^;^ 


if" 


:.»i 


[usi:.\si:s  i,r  r/ri:  hin.Mns. 


ntlNAKV  lii:i'(»<ITS  (i|;  SIIKIMKN'I'S. 
I  riii:iiv  ilr|i.)sits  ai'i'  (ruiilcd  inid  fun  riasso,  tin-  //(- 
"/•//"/('.■  iiiK I  \\\i' iin/iiiii,;  T\\t'  ni'iiyitn'r  deposits  ai'.'  tliosc 
•  •lfiiifiil>  uliicli  li.nii  |.art  of  tlic  iK.nnal  iiiinarv  .unstit- 
lU'iits.  I. lit  uliirli  l.v  rt.a>..ii  .,f  some  cliaiiHT  in  tlic  iii'iiii', 
or  i>{  an  cMo^ivc  iiincax'  in  tlirii- (|iiaiititv.  Iktmihc  in- 
solnidc  an. I  art'  |ircri|.italr(|.  'I'lic  nn/mn'r  tU-^H»\\>  ..m.-ist 
ofurti'aiiic  snl.stan.fs  wiiicli  umltT  nonnal  ciMKlitiuns  ilo 
nut  exist  in  tin-  urine,  am!  uliieli  wlien  jn'oent  tliei'e  are 
inefely  lielil  in  sMs|»ensiun. 

The  tMlI.iwinu' taMe.  .|U(.te.l  t'rnni  'IVsoii,  einhraces  \u,\U 
varieties : 

flinrt/ilini'     I )i  jKisHs, 

1.    Trie  iiiiil  (<n>iiilliiir). 

j   '/.   Acid   ^oiliiuri   iinili'  (iiMi()r|i|iims,  ncca-ioimllv  crvs- 

II.    I  rir    nc\i\    \ 

.■■■iiiIi-iukI-.   j   ''•  -^'i''  l"''''"i"'i'  iin"'' (iiiM.>i|,li,,us). 

c.  Acid  I'lilciiiMi  iiriiti' (iiiiii)r|>linu>). 

I   ''.  Acid  miiiiinniiiiM  iiiiili' (en  >tiillinc). 

III.    Wxiilutc  'f   lilllc  (ilV-tllllillc). 

I\'.    K.irlliy         I   II    Aiiiiii"iii(i.iimLcncsiiiiii  |)iiiis|ilintc  (cry.^tiiliiiic). 

li|i-pli:ili>    (  /-    Culciiiiii  pli<i-|ilmlf  ^ulii(ii-iiii(iiis  and  cry^tiilliiic). 
\'.    ('illriiilM  C!ll-tin|iiltc  (cryst«llinc). 
VI.   ('iilriiiiii  »iil|>hiitc  (cry-t.illiiic). 
Nil.    Li  iiciii  Mild  tyriisiii  (cry.-tnlliin'j. 
\'  1 1 1.   Cv.-tiii  {(■ryslallinc). 

Oi'ijiiliic  I)i  piisits. 

I.    Mucus  iiii'l  iiu>.  V.  S|>(Tnmti7,()ids. 

II.    Ki.itliciimii.  VI.    Fuii'xi  imd  iiifii.-oriii. 

III.    HI 1.  VII.    Klcmciit.'^  nfiiidilrid  ;;•.•. wth. 

IV.  Ciists.  VIII.   Knt..z..:i. 

INiiHii.wic    DIM'osiTS. 

Urii-  Ar'iil  wluMi  (le|iosite(l  a>  a  sediment  taki's  the  t'ofin 
of  uranii'e-red  erystals.  I'ldt-ss  deposited  within  a  <V'\v 
hour.'^  after  the  voidintr  <'f  the  urine,  it  is  of  little  elinieal 


^.i'r*j;iaa!«:*' 


*y*i;.»i«;tteiiiiaMiite*^sHe«Siii(^iS«^ 


//.".v/;. 


r.7 


'aci's  ImpiIi 


I'imllv  (Tvs- 


iillitii'). 
■^tiilliii.''). 


111. 

d  !,'r  iwfh. 


the  t'ol'iii 
ill  a  t'l'W 
t'  (Tiiiical 


si.r„iti.'ai..v,as  l.ralthv  luinr  will  .Irpusit  im.'  a.^i.KP  .iT.  4) 
if  allowr.l  to  iva.h  tl.r  sta.uv  -.f  a.i.l  f.TinrMtati.M..  1 1.'- 
.li.,.as,-  ill  wl.irl.  it,<  |..vs..,..-..  in  lai-v  .,H;M.titi.s  is  rliarar- 
trri^tir  i>  u^n.it:  an.l  of  its  ivlatioi.  to  thr  si.l.rH  now 
„„.l..r  .  oMsi.hTation  I  uould  say  timt  !!..•  .-iii^'f  .la..-.r  to 
!„■  aitnlHiul.'.l   iVoiM  its  i-iTsnuv  in   liH-^'  .luantm.'s   is 

Fid    ». 


I'ric  iii'M  rrysliiN. 


not  so  nm.'h  in  tin-  aiiu.unt  rx.-rrtr.l  as  in  tl..'  .•tlcct  oi  the 
.vtai.R.l  rrvstals    on    tin-  Uidiu'V-tissiu-,  .•lo.ir.irii.i;  'i).  the 
tuhulrs  an.l  i>ro.lii.'in;r  irritation  in  the  intertnhular  ti>sue, 
thus  lavinir  the  fonn.lation  lor  a  ehronie  interstitial  iie- 
,,1, litis"    Therefore  if  we  ohservi'  a  very  raphl  dei-osit  of 
nvu-  aei.l  we  apprehen.!   the  same  to  he  o.eurrin-  in  the 
ki.lnev-tissueorBome  part  of  the  urinary  traet,  either  pro- 
.Inein""-  irritation  or  forniiii,i;  a  ni<lus  tor  urinary  .'alenlns. 
I'rie  aeid  ervstals  are  always  of  dark  eolor,  ami  have  an 
infinite  varietv  of  form,  the  typh'al  shapes  l.ein-  tliose  <.t 
a  tour-sicle.l  rhomh  and  a  six-sided  plat...     They  also  ap- 
pear in  a>'i,n-e!rations  as  roseires,  in  spear-,  fan-,  and  eomh- 
shapes   ete.     The  .Ininh-hells  (.f  nrie  acid  nniy  he  distm- 
'.niVhed  from  those  .jf  oxalate  of  limo  by  their  dark  eolor, 


Kft'ellrifS: 


r'' 


M'^ 


M 


/)/.v/;.iv/;,v  or  Tin:  ian\i:ys. 


liiriffP  sizi',  iiinl  itiiilv  sdliiliility  in  iilkiilit ■^*.  Wr  iiftcti 
liml  ill  till'  iliii|M'rs  ut'  lu'W-Iiurn  inliints  red,  Lrrittv  t|i|Mi>its 
iif  iiijc  iirid  ami  iii'mIc^.  flic  iia^-^ii'/i'  "I'  wliirli  uivi^  lliriii 
lintcli  pain. 

/'/■'■    .|r/</     (  'nioiiiilllii/^. — 'I'llf    llliltrs    nl'tlli'    ill  kllli'-    iU'C 

iTi'in  Tiillv  (ii'iKisitcil  ill  llif  urine  as  an  anioi'iilioiis  |i(i\v(liT, 
varviiiL;' in  color  fnini  llic  hrick-iliist  or  "  latciitimis"  iK- 
jiosit   to  an  alnio>t  ulii.c  sciliiiicni,  tju'  color  (li|a'nirMi,i.' 

Fill.  r,. 


I'mli'  111  MMJiuiu. 


u|ioii  tlic  density  and  (olor  of  the  urine  iVom  wliidi  it  is 
deposited.  This  sediment  may  he  t'ouiid  in  tiu-  urine  of 
lu-atthy  persons,  where  it  is  of  ii  liiLfli  ih'iisity,  acid  reac- 
tion, and  low  temperature,  as  after  profuse  sweatiii«r  or  in 
viry  cold  weather.  I'atholoirii'al'.y  we  tiiid  the  di'posit 
occurriii!.r  most  Ireipieiilly  in  fehrile  conditions. 

Heat  will  dissijiate  any  cloudiness  or  deposit  of  urates. 


■  :?;'.:j. ^ij-V?ii.-;.jt«i'!^.?t . "S f  i '-i'  -54 tf't  •(■.'tfiSii^' 'ii'ii 


W'r    lift.  11 
ivf<   tlirlii 

kiiliis  iin- 

«  |Mi\V(liT, 

fiiiiH"  ill', 
liluiidiiiir 


iliicli  it  is 
•  urine  of 
acid  I'ciic- 
itiiiLT  of  ill 
ic  (U'jiosit 

of  urati's. 


"■^^;,;::;,;r:;;::';;:l:hi. •,■> - '-h— >"■ 

<"'-  - "  >^"'':.:;"';:t;:u";:ii  i- •> >"■ 

•1" "■"■"   ■",'        ■"   '  '    .,,„i,,.v.taU..rtri|.l.-pl'"" 

'''  .  ;  .  .".rv^fiHiMr.  .n.l  UM.Ur  tl>r  .uu-rosn.l.c- 

:r:;:i::;n;;'H::^M'...-- "■■ ■"•'"■"'•- 


Fid.  0. 


/c 


'^ 


0    '^a  ^^'l^ 


oi- 


'  *% 


(»xi\liiUM)rUnu<ry-taH. 


.,„.  .■,.,.,„a,i —,.... .Hi ■;.;:;'•':,•;"•  1,:',: 

■■'■"- " ■■''■';''':,r;;:;.'  u7mi;■,.,n.r,l,.■ 


::5S?^;7i5?^^ 


r 


m 


/•/s7,|v/.s  »>/•   /•///;  hil>.\His. 


\  , 


nxiilntf  tA'  lime  in>t;il-<.  Ollur  iiiitli«»rs  cuiitciiil  tliat 
•  (.Miliiir  «if  lime  is  (liTivnl  irniii  a  (k<t»iii|M».'4iti(iii  of  uric 
iii'iil  iiikI  iiiMlcs. 

n\iilalf  of  Unit'  ti\-.ti(l.  !i|i|ii'at-  in  a<ii|  mine  unlv. 
'I'luir  Hlia|ii'  i^  wvy  ilmnKicii^ti  •  '\\\n  t'urms  arc  nid. — 
llic  Mctalicilia  ami  tlic  iliimli-licll  cr_v>tals.  'I'lic  octaliciira 
arc  tiaf,  retract  the  liirlif,  ami  sunictinics  a|i|icar  as  nicrc 
I">int-,  wliilc  at  ntlicr  tinns  tlicv  assnnic  tlir  cnvdnpr 
hliapc.  'I'lic  clinical  sii^niticancc  of  tlic  oxalate  of  linic 
crystals  is  almost  iticntical  witli  tliat  of  the  apiMarance  of 
urate's  in  the  urine;  hut  ulnii  the  (hiinh-h.ll  form-  aie 
met  \vi'  shouhl  Itcar  in  mind  the  tint  that  thev  are  in- 
clined to  aecumidate  in  the  tuhuli  urinifcri  and  form 
calculi, 

E<irth>i  rhnsjihiil,  -:. — 'I'lic  amor|>|ious  ciirthy  |ihos|i|iateH 
are  fr»M|Uentl_v  found  in  urine  that  is  alkaline,  ^^Y  that  has 
umK'rirone  ammoniacal  dectuiiiM)sitiou,  as  a  _t;ravi>h-u  hite 


Fill.  7, 


AMiiniiiiiiiiii  |.|ic>s|i|ial('<i. 


Sediment.      Any  cause  which   occasions  alkalinity  t>f  the 
urine  may  jiroduce  this  sediiuent.     The  crystallized  idios- 


'"'■'Xik.'i^iy'i'-'.'','--^'''-- 


■  r^-^i'-^fm 


I  i!i.\r. 


t'.l 


•  nil  iliitt 
HI  nt   uric 

irif  Kiilv. 
re  iiu't. — 
M'talii'ilia 
r  as  inert' 

lll\  clnlK' 
1'  of  lillM- 
llillicr  III' 
iillllS    illi' 

y  arc  iii- 
iihI    roriii 

ii>s|t|iatcn 

tliat   lias 

isli-wlilto 


y  of  the 

L'll  jlllOlS- 


,„„...,,..,M„„.i.,.,n.ai..   ,.al,.,  tan.tlv.a...l  unn...  an.l 

r.l,iL('J' '■  i.ara.v.l.l.u.ii.Ml..m.a.M.n.uJmt 

i.  IUM1..1  al.MU.IaMtl.N  intl.at  ..nl...  h..rsi-. 

r././ .sw,/""- ■'-''- "••"•■""••"""■>  ^'■"""■'  * 

„,i„„  u|,i,.l,   U  l.„ I  will,   l,ili„n   ,..I...M.v'.iMa.l,..-.    "-I 

;;,,;,„ii,;,Mv ■.,.„v,.,ii...a«,.;ni..>iv..- ,.-.,.,.  .v..ii..w 

iiti'.ii.liv  ami  iihuM.lioni^  iM)is..iiiii,Lr. 

"";•,,,..,!   ..rl ,    ...li n.,  wl.i.L   .l.v.l..i.-|" 

,„„„',„■  s„l,l,m..>„..n..v,ln.,,-.  ... -11  -  ,.1  um,u,m,a  u, 

(IccMiniHisetl  iiriiif. 

oni;\Nii'  i'i:i'n-irs. 

J/.,... //•...--Nln.us.xi-Ninv..rvHnallMnanri.Yn 

h.al.l.v   MHU...      1.    f..nn.  a   lain,    tlo,...nl..n,   .Ion,)  win-  , 

l.;,,.wanl.lH.   louM-  ,,ar,nr,l,..l!uu    al.HM^^^^^^      .- 

,.,.,.   ha.  1 n  allnuva   .o  Manil   ..m.  .MM.   ana   .s  ..o,n- 

,: I    ..,•   epithelial    ..■11..    n.un.l    .raunlar   l.u.l.es   ..alle.l 

,.n,.us.e..r,a,seles,  a.al    a    llnia    ,--ti.n.  the  /-r-''    """'• 
\\Mmmm.h  ens  is  luvsent  in  lar.e  an.Mun.  >t  .hn.    e>  s.,,,H 

Lnrl.un.o  in  tin.  urinary  traet.  ana  wlu.M  the  ae,.n.e  ..t 
;;;.;;;;.,.anee  increases  thoeharaeteruf, he  .le,,.s,t  ehan,es, 

»•';'  l?'^^^•'''  '": 'n;'':,, ,  ,,.,,,i,l,.n.sta^e  to  .listin^uish 
t     s   iiiiiio>sil)U'   m   the   tian>nii'n    u  ,_  , 

1     ,    .nul    1,11^-colMinsc  iS,  hut  111  tlK' 

Uctween  iiiueus-eoq.useh.s  an.l   i.u>    .'  |m,    i 

,,ter    Sta...-S    the     ,.U>-eor,.US..les    will     ho    ohsenea    to    1k 

,  .  ,,„.,.,,an,lyVu,,.lu..l  -ith    nudei  than  the  mueus 
l,,n<..les.     Solon^J.owevei-.asunne....nta,nn,^nn    u. 
i,  ^ vithout  alhun.en.  so  h.M- inay  i.us  Ik- sahl  to  1..  al.sent,  as 

,„„.,„.  i,...f  eontains  no  alhnnien,  while  pus  a  ways  .loe>. 
r;'in!,.ontainin.  pus  is  turhi.l  an.l  inilky  when  voi.le.l. 

„,l    ,,ur    stan.lintr    awhile    .lep-sits   a   aei.se    yelh.w.^h- 


,-.'i)t,u»<ii  ;„ '  jay«S* 


DisKAsKs  or  Tin-:  KiDyKis. 


wliito  si'diinc'iit.  Wlini  tlu-  uriiu-  is  alUaliiu'  tlu'  pus 
cnlicrcs  into  11  viscid,  li'iimiitiis  mass  wliicli  ciiii  1k'  drawn 
(Hit  into  Idiiu:,  t(»u<;li  striiitjs.  lU-alu  iin'iitioiis  tlic  tact 
that  Jills  is  tVc(|iu'iitly  met  with  in  thi'  iifiiic  ot'  iicrsons 
past  till-  mi(hlK'  jicriod  of  li!c  whose  n-ciicral  licalth  is 
iCood.  It  slioiild  not  lie  I'orii'otteii  that  in  I'einali's  pus  is 
apt  to  appear  in  the  urine  Iron i  leueorrhiea  or  othir  puru- 
lent discharp'  from  the  vaii'ina. 

When-  the  alhuiiien  contained  in  purulent  uriiu'  is 
larsii'  in  amount,  it  will  ho  well  to  luuk  closely  for  renal 
easts. 

Jilniji/. — Trine  containini;  Mood  from  any  jmrt  of  the 
urinary  tract  will  always  contain  alhuiiu'ii.  The  urine  is 
usually  smoky  wlu'ii  the  hlood  is  derived  from  tlu'  kidney, 
unless  thwre  is  a  tree  liemorrhiii;e ;  when  the  liloml  is 
derived  from  the  hhulder  the  urine  is  often  of  a  lirii:-ht 
red  color,  or  the  hlood  comes  in  clots.  AVhcii  the 
lu'mori'hay'e  is  from  the  urethra,  it  either  jirecedes  or 
follows  the  How  of  urine. 

IJlood  is  usually  doiiosited  from  the  urine  as  a  ri'ddish- 
Iirowii  sediment.  The  color  of  the  ijlohules  differs  accord- 
iiiiT  to  the  reaction  of  the  urine,  heinu*  of  a  lirii^hter  red 
when  the  urine  is  neutral  or  alkaline,  and  dark  or  lirown- 
ish  where  it  is  acid.  Examination  hy  the  microscope  is 
the  surest  method  el'  diiiirnosis;  althouj;h  in  urine  of  low 
specitie  tjravity  and  in  ammoniacal  urine  the  corpusiles 
disappear  very  rapidly,  Tt  will  be  sei-n  that  the  cor- 
jiuscU's  do  not  run  into  rouleaux,  as  they  do  when  drawn 
directly  from  the  blood-vessels,  but  ajipear  distii;r't  and 
separate.  Where  the  urine  is  dilute,  the  corpuscles  ex- 
pand from  imbibition  and  a}iiiear  as  delicate  cirifles 
without  visible  contents;  where  it  is  more  concentrated, 
they  are  small  and  preserve  more  of  their  biconcave 
contour,  and  at  times  are  shrunken  and  nn>Jsliapen. 


Liiiyi:. 


t;:5 


'  tlu'  pus 
\k'  (Iriiwu 
■;  the  tact 
^t'  luTsoii-i 
lu'iiltli  is 
Ics  pus  is 
lliii-  puru- 

uriiu'  is 
tor  rc'iial 

irt  (if  tlu' 
\v  urini'  is 
10  kiiluoy, 
l)lo(nl  is 
:'  a  lii'iti-lit 
Vhvu  tlio 
o<'(.'<li's  or 

a  rrddisli- 
'I's  arconl- 
iu;litt.'i'  I't'd 
or  l)ro\vn- 
I'osc'opo  is 
iuc  of  low 
.•orpnsclt's 
the  cor- 
K'U  drawn 
itir.'^'t  and 
usc'les  ox- 
to  (.'ircles 
ceiitratod, 
liii-oiK-avo 


(VW..-T1U.  sul.)..t  of  ntsts  is   fully  discussed   in   the 

followiiiii  ehai'tcr.  r       ,  ,     .c  fi... 

N/..../..--./.^  iVe,uently  o....ur  UJ   the  sedmu.    .   o 

,t-  healthy    men.      When    ahnndant    tl-N      '.       a 
i.ht  tloe.ulent  elou.l  in  the  urine,  hut  .generally  then    . 

.o^hin^intheappearan nluMjri.K.  whu.h  wou  d   .^^^^^ 

a  suspicion  of  their  presence,  and  they  nu.st  he  .hauuo.ul 
l>v  the  microscope. 

,„„„r'i„  ,u.c.,n„.osn.«  «n..  uln.h  w...  t".--- .    ...  U    1 

:  :    .hlo  h,  .l,..ir  .«,„■■,.,  «n.l  »>■..  „su„n,v  u,,.,.        ;.  ;  .- 
,V;,,K.nt  .>!.......'  tlu.n,  »,v  l....tc..-,a.  ,.om..,lUm,  ,.-1.  .."... 

,,,,,.,.,. f„„,n,s.     S»r.ni...  ..l-.  im-t  with  ocn..m,..ll.> . 

„,.  ,,    ,K..     C.lls  .„■  .■,■»,'>.,.„.»  ..f  a  gn.^.l.  ma,  l..  !....„., 

,    ,  ,„„st  1...  r«u.,ul,wv.l  that  aln,..st  every  .-l.al.u  ..I 

a    ari..  .V...n  .1,.  cells  of, ho  l.la.Wcr  .lurmg  uMla.a. 

,,.,„•  ,„,  ;,,,i„„u,„.      Frag,m.n,»  of  canccn.as  p  «    1, 

„,  „,„,   „,„,,  w„yin.o  ,l,c  urine  a-  f'-™".^  "' 

vill.ms  variety,  an.l  .t.ay  k1,„w  tl,e  ea,„llary  ve-.el»  that 

'"t:t"».a«re.eW.,,nti,,,,,.ii,,,i.e„,-i..ei...l.^ 
,,-,t..e.  TItere  have  l-ve„  several  i..sta„ees  ■„  wl„..h 
eelmmeoeeus  evsts  aiul  h....klets  U'ere  ohserve.l. 

.I..l,„  Harley  f,.u„.l  in  the  urin,.  ol  several  xtttents 
sntle.'in.'  with  the  en.le.ni.-  ha-matana  »i  .< '^^  (.''l"'  "/ 
G,!;,ni;.,.e  thee,.,san,l  eiliate.l  e,nhry.,s  of  the  litlhar.ta 

''The'ih:,'ia  ««..«ni,,is  l.ontinis,  the  ..arasite  whhh  h,. 
,J„    shown   to    have    so   intin.ate   an    ,tsso«a„..n    w„h 
ehvhiria,  is  sometimes  fo.in.l  in  the  tmi.e. 
^'  bilto,;,a  ha„na,.,l.in,n  has  heen  '""n,    .n    he  hla.l.le, 
ureters,  an.l  velvis  ..f  the  ki.lney,  espeetalK  ...  I.»l"- 


■■ 


64 


DisHAsKs  (>/••  Tin:  hiDMjys. 


(MI  A  I'TKIi    IX. 

CASTS    Ol-    Till-:    ntlMlKIUHS    TllilLES. 

TliK  ipri'si'iico  of  rusts  in  tin-  \iriiu'  was  first  olisiTvcd  liy 
Vuula  ill  ls:57-3.S;  Simon  of  lU'i-liii  also  tU'scnluMl  casts 
in  iiis  "Medical  Clu'iaistry"'  in  1S4:2;  Kayor  mentions 
tlu'm  as  early  as  1«:iS;  iiut  none  of  these  oliservers  made 
any  attemjit  to  exiilaiii  their  tuigin,  stnu-ture,  or  signirt- 
eaiiee. 

Jleller  apjiears  to  have  been  the  first  to  offer  an  exjila- 
nation  of  their  origin,  Imt  he  also  t'aih'd  to  apiu'eciate  their 
import,  a  careful  study  of  vhiidi  is  a  matter  of  recent 
date. 

r.eale,  Johnson,  Dickinson,  (iuU,  (Jrain.ii'er  Stewart, 
and  many  French  and  (Jerman  writers  havi-  y-iven  tho 
ori^'iii  iind  dia^'nostic  value  of  urinary  tul)e-casts  careful 
attention,  as  also  have  Millard  and  other  American 
writers. 

Meyer  says,  "The  casts  are  iirodnets  of  an  alhu- 
miiious  exudation  from  the  hlood-vessels  plus  the  swollen 
and  destroyed  eiiithelium." 

C'hareot  is  of  opinion  that  some  casts  are  composed  of 
broken-down  epithelial  cells,  and  others  of  albuminous 
substance,  while  epithelial  casts  consist  of  epithelial  cells 
more  or  Ic^ss  altered. 

Cornil  believes  that  casts  are  the  result  of  a  jpatholo.ii'i- 
cal  secretion  from  the  cells  of  the  convoluted  tubes,  wh'ch 
olttain  the  nniterinl  for  exudation  from  the  neiirhborini? 
capillaries,  and  that  the  epithelium  is  descpiamated  in  the 
straiirht  tnbes  only. 

Millard's  theory,  that  casts  are  invariably  an  albu- 
minous   exudate  into  the  tubules  from  the  surrounding 


^m 


r.i.sT.s'  OF  THE  nii.\'ii-i:ii<>is  tiuilex- 


(■),'» 


ihod  (lists 

luciitioiis 

vers  uiiulo 

of  siiTiiiti- 

an  cxjila- 

ciiitv  tlu'ir 

of  ri'ft'iit 

•  Stewart, 
iiivcn  till' 

sts  can' fill 
AiiiiTU'aii 

ail    all)U- 

1r'  SWdlll'll 

111  posed  oi 
ll)Uiniiious 
lu'lial  colls 

patholou'i- 
Itys,  wliA'h 
L'iirliliorinu; 
[ited  ill  the 

•  an  all>u- 
irrouiuling 


cavillarioH  wliieh  saturatiM,  diste.i.ls,  and  leads  to  partial 
or  entire  destruetion  «.f  the  epithelium,  appears  to  n.e  to 
he  the  one  most  worthy  ofaeeeptanee. 

(\ists  may  originate  in  any  part  of  the  nrinitenms 
tuhiiles,  and"  may  even  ho  found  in  the  Malpi-hian  hodies 
S.mie  writers  state  that  most  .'asts  are  f..rmed  m  the 
Htrai.M.t  tuhes;  hut,  as  the  east  is  an  exmlatioii  Ironi  the 
hlood-v.ssels,  and  as  the  eortieal  portion  <.f  the  ki.lney  is 
nuieh  more  ahundaiitly  supplied  with  vessels  than  the 
nvrami.lal  portion,  it  seems  reasonahle  to  suppose  that  tlie 
exii.lation  is  more  likely  t..  take  plaee  into  the  eonvo  uted 
tuhules  of  the  eortex  than  into  the  strai-ht  tuhos  ot  the 

^'^rlllis^range  from  .^^  to  rh^  of  an  inch  in  dlanieter. 
Their  shape  is  determined  hy  the  si/.e  and  form  ot  the 
tuhe  from  whieh  tliey  are  derive«h 

Thev  are  the  result  of  inflammatory  exuchition,  witli 
the    exeeption    of  the    hlood-east   oeeasionally    found    m 
hvpera>mia,  either  aetive  or  passive.     It  is  usual  to  rhissity 
casts    according   to    their   structure;    that   is,   epitiuoa., 
hvaline,  granu'lar,  tatty,  waxy,  and  hlood  casts. 
'  F.pitI   '.    1  and  hlood  casts  occur  in  acute  nephritis,  and 
•ire  the  result  of  a  fihrinous  exudation  containing  a  few 
hlood-corpusclos,  into    the   uriniferous   tuhules,   destpia- 
mating  and  entangling  their  lining  epithelium.     (  asts  ot 
coaiTuiat'  I  hlood  sometimes  occur  in  hypenemia,  either 
pas>i\e  ar  active,  and  in  hannaturia. 

Hvaline  casts  are  the  result  of  an  alhuminous  exudate 
into'a  tulnile  already  devoid  of  epithelium. 

The  .--ranular,  hyaline,  and  waxy  casts  are  more  com- 
monly t?nin(l  in  intertuhular  and  chronic  tuhular  nephritis 
A    .n-anular   east   contains  degenerated   epithelium   and 
l.lood-corpusdes.     Fatty  casts  are  simply  the  result  of  a 
further  and  fatty  degeneration  of  the  exudation  and  eon- 

c* 


^■teo 


66 


nisKAsF.s  OF  rut:  KiuyF.vs. 


tiiiiu'd  fi.itlu'liuiii,:iii(l  i!.:iy  occur  in  cither  iicutc  (ir  chronic 
nephritis;  whih'  the  waxy  cast  is  a  waxy  or  hmhiceous 
(k'^ciicration  of  the  name  i-k'nients. 

Itohin  is  responsiltle  tor  tlie  statement  that  tube-c  iHts 
are  sometimes  fonnd  in  urine,  tlie  excretion  of  a  jicrfectly 


Fid.   H. 


TVDE  Casts.—:,  criinular  casts;  2,  hyaline  casts;  3,  waxy  casts;  4,  t'liUhclial  casts; 
5,  blond  casts  ;  6,  fatty  citsts. 

normal  kithiey.     Tliis  view,  however,  is  as  doubtful  as  la 
the  existence  of  physit)logical  albuminuria. 


ClIAPTEK    X. 


ALBIMKN'. 


As  the  presence  of  albumen  in  the  urine  is  the  charac- 
teristic feature  of  inflammatory  diseases  of  the  kidney,  it 
will  be  well  to  refer  brietly  to  it  before  proceedin.u;  to  the 

tnsideration  of  those  diseases.  The  views  of  the  medical 
world  as  to  the  part  that  albumen  plays  as  a  symptom  of 


M 
I  i 


iiMi 


. ,.'  .*.'».►.• 


.i/,/.T.u/;.v. 


67 


ir  chronic 
mlaccous 

hibc-c  ists 
])crt('ctly 


UhfUa!  casts; 


btlul  as  is 


he  c'luirac- 
kidiK'V,  it 
linu;  to  the 
le  nu'dical 
mptoiu  of 


a  ■-.imrii  i»  iiiMih   .u«.i>»  I'l'  >'  .,.,,1  „i„l,.r 

i-iiK.  •tiiciit  ot"  the  kiiliicvs. 

"  ^^    "     wc  now  hcu;  ...uch  on  the  subiect  ot  l-hy-o- 
JLa  aihunnnnria,  hut  alhunuM.  in  the  nnnc  .s  no   eon 
li.Terea  physioh,,ieal  where  it  is  in  excess  ol  one-thutath 
or  one-fortieth  of  one  per  cent. 

For  n.v.clf.  I  <h.  not  believe  that  albumen  ever  exists  ,n 
ti  J  llle  with  a  periectly  nornK.1  eondition  of  the  knlneys 

'^'lu!;;;!   n.y,  it   is  true,  aH>oar  m^^^^^^^^^^ 
hcartv  meal  consistin.u'  of  albununous  lood,-e->,  tc, 
He-  after  prolon^n-d  an<l  excessive  n.ental  or  phssu  d 
^^nlin     in    asesofoveractionoftheheart;dnm.,he 

:  2..;i  severe  ehills  of  nndarial  tever ;  oc..s.onally 
Inrin.^  the  course  of  tlie  acute  ndc'tums  d  sea^o  .  and  tt 
is  u  t'n.u.sual  in  the  course  of  an  attack  ot  vneunnuna 

I    .V  of  these  eircumstances,  however,  it  ,s  no    phys- 
,,WU^    dbunnuuria.      The  kidneys  are  probably  ma 

vp^r^nuc  condition,  or  the  tiltrati<.n  ot  f^-^^'Z^^ 
due  to  a  slii^^ht  degenerath.n  of  the  epUheha  ot  the    idt  or 

0  a  pathoi;.ieal  eondition  of  the  blo..d ;  ,.r  perchance, 
n  Lml  cas^,  albumen  is  secreted  by  the  epUhebum  ot 

0    u  nles.-    Xow  and  then  we  nu-et  with  a  patient  who 

enbnin.  apparently  perfect  health,  but  whose  urme  toi 

;       hL^ielir  been  long  free  from  a  tra..  ot  .  bumeu 

1  have  two  such  patients  at  the  present  tune.     It  i^m 
po    U  le  to  Bay  exactly  upon  what  cause  the  presence  ot 


t;s 


i>isj-:asi:s  or  the  kidsevs. 


alliuiin'ii  ill  tlicsc  Clip's  (lc|ifii(ls,  liiit  it  (lots  iHit  rc'iuirc  ii 
vt  TV  li\fly  iiiiiiiriii;itiiin  to  siipiiosc  that  tiifiH'  is  an  aluiiir- 
iiial  (11'  |iatliolo<;ical  condition  ot'  the  cjiitlu'lial  liniiiif  of 
tlif  tulmk's  or  tut'ts,  or  an  almorriial  coiiditioii  of  the  Mood 
or  lilood-Vfssfls.  I  liavt'  known  in'oiilc  to  he  in  fairl.v 
li'ood  licaltli  for  tiftv  years,  with  a  luitlioloiiical  condition 
of  the  lirojichial  niucons  inondtruiu' or  a  <'atari'hal  cystitis. 
Manv  |>crsons  enjoy  i;ood  health  for  years  with  atlu'mnia- 
tous  arteries. 

Xnnierous  theories  liave  hi'cn  advanced  to  exphiin  the 
preseiici'  of  alltnineii  in  the  urine.  Some  helieve  that  it  is 
due  entirely  to  a  patliolotrieal  eon<lition  of  the  Mood; 
others  attriimte  its  presence  to  an  alti-red  condition  of  the 
vi'sscl -walls  or  epithelinnj :  while  the  theory  of  chanires  in 
the  vascnlar  tension  as  a  cause  has  its  adherents. 

r  iK'lieve,  with  Sti'wart,  tliat  normally  the  hlood-pressnrc 
in  till'  caiiillary  loo|is  and  walls  of  the  vessels,  with  their 
thin  eiiitlu'lial  coverini;,  is  so  halaneed  as  to  permit  the 
transudation  of  thiid  and  yet  prevent  the  [>assa_i;e  of  alhu- 
men. 

Of  the  theories  holdini;  tliat  alhnminuria  de]ten(ls  upon 
hlood-chanjres,  the  most  plausihle  is  that  wliicli  rei^ards 
the  excess  of  salts  as  the  causi'.  Kxperiments  have  shown 
that  when  the  salts  in  an  alhuminous  solution  are  increased 
the  alhunien  transudes  more  readily  throusjli  animal 
mend)rane,  and  it  is  possil)le  that  this  prineii>lo  holds  good 
as  regards  the  hlood  also. 

When  the  halanee  of  pressure  in  the  glomeruli  is  dis- 
turhed  hy  increased  heart-action,  or  when  the  vessel- 
walls  or  epithi'lium  are  diseased  from  inflannuation  or  a 
pathological  condition  of  the  blood,  as  in  scarlet  fever, 
jioisoning,  venous  stasis,  hlood  glandular  diseases,  etc., 
wc  naturally  expect  the  transudation  of  albumen  to  re- 
sult. 


jar. 


TESTS  Fon  M.nrMHS. 


69 


1„  .U-om-ration  of  th.  opitluruMU  th.  i.n;sr„.v  ot  all.u- 
nK-nin7lu-unuoistlu..vs,.lt..ftuo....u.it.ons. 

Fir.tJu.n^asinotl..^,:H•.s.,^.lu.l.o.ly,wlH.un.;u. 
,,,,;.,„  i.  ,n.sc.nt  tlK-n.  will  b<.  an  Ml.unuMo.s..^^^^^^^ 

soc-otullv,  as  tlu.  rcs.Mt  of  .U-s,na.nat,on  ot  tlu^  .p'tl"    ' 
,„.l  ..onso.,.u-nt.hau,..-s  in  tl..  hasc-nent  nu.,nl.ra.u.,  tin  .. 
will  iH.  a  fnv  transu.latio,.  of  ulb.n.u-..  Iron,  tlu.  v.sm.1. 

into  thu  t»il)iiU''<. 

TESTS    KOU    ALIilJMKN. 
I„  all  instances  wlKT.  tluMU-ino  to  ho  U.Hto.nsn.>nH.r. 

,V,,tlv  rU.a. ,  it  shouM  »H.  Hlt.rcMl  hofo.-o  aiM-lyn^M h.  t.sts. 
T;-!;nn.yi:eaon.inan.wnnnnt.s.,ymo..s..;  n.^^^^^ 
,,,„,,  or  ahsorlK-nt  cotton  and  a  tnnn.l.  1 W  mo>t 
!Xi,le  tests  tWr  aUnnncn  are  the  heat  tost  and  the  n.tr.e 

A  te<t-tuho  Is  tilled  to  one-fourth  or  one-third  of  its 
depth  with  ,.erfeetly  elear  aeid  nrine,  a.ul  heat  a,>,.he.l 
S. , oiling  oeenrs!  If  turhidity  results^  U  .  dt.o  ho 
.resenee  of  albntnen  or  of  phosphates.  It  eans..!  hy  he 
atte-  the  tnrhidity  will  disappear  on  the  add.tton  ot  a 
IjlX-onutrie'or  aeetie  aeid;  if  hy  allMunen,  the  tur- 

hiditv  will  ho  i>ennanent. 

'"X^  .xeelU-n^dan  is  to  apply  heat  to  the  upper  i....to,. 

of  the  nrine,  whe,>,  by  contrast  with  the  elear  ur.ne  helo.  , 
the  slightest  cloudiness  will  heeonie  apparent. 
KItrir  AH'I,  or  H:'ll<'-s  llsl. 
Upon  a  quantitv  of  pure,  colorless  nitric  acid  in  a  stnall 
tost,  ubo,  allow  to-  trickle  down  the  sides  ot  tlu-  tube  tnn 
V  pi pett  ,  an  enual  amount  of  clear  urn.e,  wh.ch  shoulu 
;.4H;etheacid!n,>tnnxwithit.     Ifalbutnenbe,.^^^^^ 
•It  the  poi.it  of  contact  between  the  nrine  and  the  n  t.u 
'leid  tlLro  will  appear  a  sharply-dotine.l  wlnte  ban<l  or 


70 


/)/>/, MSA'S  "/••  77//;  /»■//' v/;j'.v, 


Fill.  't. 


zoiif,  wlii.h  will  viirv  in  lliirkiirss  iir.-..r.liii,u-  t..  tlif  (|U:iii- 
filv  of  iill.miini  piv^riit.  I'ratrs  ..r  tlir  ivsiiis  ini,L:lit  1m- 
mistiiUi'ii  fiT  ihr  wliilc  /(111.'  (.f  :ill.iiiiicii.  'riif  loniHT  is 
less  distill. t.  with  pourly-ili-liiicd  iii;irunii>,n><iiil.liii,';><>iiu'- 
whiif  11  .loud  of  siiiokf,  and  on  .'XiiniiniitioM  will  !•»■  seen 
to  diU'iis*-  ils.ir  into  tlu'  nrinr  iiliovc.  Ilfiit  will  dissiputc 
the  .loud,  whiK-  it  will  intensity  tli.'  x.oim-  t'ornud  l.y  al- 
liuiiii'n.  It'  111. oil.)!  ln'  inl.K'il.  tin-  /oiii'  t'oi'nu'd 
l.y  till'  r.sins  will  di-.ii|i|M'ar.  while  that  of  the 
alliunifu  will  lu'i'onu'  uioih'  niai'U.'d. 

(  Hill  r  tots  in  list'  ai'c  tlir  \>'u'v\r  acid,  sodium 
tuntrstatf,  |iota-sio-nifr.Mirii'  iodide  ft.-.,  lor 
lurtluT  iiifonnation  con.'fiMiinu'  which  I  rcl.  r 
volt  to  Tyson's.  Ucalc's.  Uol.crts's.  and  otlu  r 
I'Xci'Ucnt  w.»rks  on  the  pnn'tical  cxaminaiion 
of  uriiit". 

For  the  ([uantitativc   analysis  of  alhunicn 
the  most  eonvt'uieiit  method,  and  a  sullici.'Utly 
iu-eui-ato  one.  is  that  of  Ivl.ach.      A  tul.e  t-Tad- 
nated   lik»'  that  in  Ki.ir.  !•  is  t..  he  em|.loyed. 
Dr.  Hshach's  test  solution  is  preitaird  hy  dis- 
solvintr  ten  u-ramines  of  jiicri.-  acid  and  twi'iity 
-rfanimes  of  eitri.'  acid  in  nine  hun<lred  cuhic 
eentimetiTs  of  hoilMi-r  distilled  water,  addinir, 
when  cold,  siitHcie  .r  watiT  to  make  one  litre. 
The  liltered  aeid  ui-ine  is  j.oufeil  into  the 
irlass  tuhe  up  t.i  the  mark  f\  and  the  fi'airent 
is  added  till  the  U-vel  of  the  li.iuhl  stands  at 
}i.    Mix  the  li(|nids  th<u'ouirhly,  without  shak- 
imr,  hy    iH'vei'sini;    tlu-    tuhe   a   (h)/.en   times; 
close  witli  a  cork,  and  allow  it  to  stand  twenty- 
four  houi-s.     The  heit;ht  at  which  the  eoairu- 
him  then  stands,  read  off  on  the  scale,  will  indieato  the 
nuiuher  of  pai-ts  per  tliousmul  or  grauimes  of  albumen  in 


11 

II 

SI 


K'.lliull'!.  lllbU- 

mm  iLutrr. 


inritiA—i'inrriiiA 


71 


o„.  litre.     T1,H  .livi.lr.l  l.v  t.n  will  pv.  th.  ,u..v..,»tn^r.. 
p.Mitr./.t  numot  1..  a.vurat..lv  ...thnuMl  l.v  tin.  nu.tlwHl. 

\\V  M...  tlu.  t.nn  i.vum  t..  iMMi.at.  tl.M''--'^--'-' '''^^  ^ 
;„„,,,„,;,„,  ,.,..nlK.ss  of  tlH.,-.'t   uf  t W  unn.ry  tn..t 
,,.,,,,;.,,  Ui.M.nv.l:  just  us  w.usMl..wonll..-m:. 

have  S....M  in  stu.lvin-  tl..  .litK.vnt   <l.s.as.s  ..t   th.   U.  l- 
;      that  ,Ms  a,,:ars  in  tlu.  miH.Mnul.r  a  ,n.at  van.ty 

/..n.litil.ns.   111     hav nsi.U.n.l     tl.    ..u.lu.y    an- 

.,,„„,„.,.  of  tlH.s.  ..on.litions.  N.v..rtln.U.ss,  on  a-you  t 
:,-theh;M.ortan..oftlH.,n...n..of,usn.tlu.u^^^^^^^ 

,  „„.U.r  of  .lia.irnosis  an.l  ,.ro,.M.os,s,  ,t  n.ay  l.e  «.l  t.  .  u. 
now,  nn.UT  tin-  Load  of  l-ynria,  to  c.,>Uon.u.  tl.o  .tK.  ..^^ - 
,,,  ,i,vu.nstan.-c.s  an.l  patholopcal  <M,n.ht.uns  an.!..-  u  In.  I. 

''  XC-I"  tl-  l<i.ln..y  itsc-lt;  i.y..litis  <.r  ul-vrat^ion, 
nl,....ss.'.s  ...•  tul>.Mvula.-  ki.ln.'v,  an.l  ,.er.m.i.hnt.s  wIkt.. 
tlH.  abs..oss  oiK-ns  into  the  i-olvis  ..f  the  knlm^V,  w.U  -ins.' 
.vuria  lTrot..ritis,  .-ystitis,  ahs.-.'ss.'s  m  th..  snl.nuu-<.n. 
ti..ne  .'^f  th.>  hla.hU-r,  r.'ri.-ystitis  ..r  lu.lvi.-  ahs.-ess..s  o,..-n- 
i,;,:  into  the  l.la.l.ler,  an.l  urethritis,  always  ^nv  pns  m 

'^'^•;;;;:i;,--There  will   l.e  no  .litH.-ulty  i,.  .lia^n-.sinj, 
pus  i,;  the  urine  if  th.-  urine  is  alkaline  fr.>m  anunonnu-a 
U,.,.„n,><-tion.      Vn.ler    su.-h    .-on.htn.ns    the    ,>us 
,,,  J  into  a  visei.l,  tena.-i.ms  n.ass  whu-h  ..an  1.  .Irawn 

out  in  lonsr  strinu^s.  If  the  ur.ne  he  a.M.l  the  l-us- 
,.„,,„seU.s  will  he  .listin.-t,  an.l  .'henueal  an.l  nu.-n.se..- 
.i.,!,l  .xan.inations  will  he  ne.-essary  t..  .let..rnnne  he 
lia-nosis.  Urine  that  .'..ntains  pus  is  always  n.ore  ..r  less 
turhi.l,  the  .le^^ree  of  turhi.litv  .lei.en.ling  ui...n  the  am..unt. 


/>/.s'a;.i.va;.v  of  rm:  KinsHvs. 


uf  \\\\<  iPiisciit.  Al>r.(iliif<  Iv  clfiir  mine  ilms  not  ((Hitiiiri 
|»Urt.  All  liiriiid  iiritic,  linwcvfi',  diu's  not  ii*'r«'H.saiilv  (i>ii- 
tjiiii  |.iis.  Tile  tmliiilitv  iiiiiy  il(|ifii(l  ii|m)|i  catiiiilinl 
iiiiirii>  iViiiii  tilt'  liliulilci' ur  tidrii  till'  |ii'l\  is  (if  tlic  ki(|iii\  ; 
III'  it  iMiiv  lie  <liu'  to  tlir  |iri'si'ii(f  III'  |ilHis|i|iiiti's  (ir  urates. 
'I'lie  tiirliiilily  laiised  liy  |iliu,-,|i|iates  will  «lisa|i|iear  (Hi  liie 
aililitiuii  (it' an  acid  to  tlie  heated  mine;  that  (if  urates  will 
(lisa|iiiear(in  tlie  a|i|ili(ali(in  of  lieat  aIon«'.  Tlie  turKidity 
(if  acid  urine  (diitainini;  pus  must  increase  on  tlie  apidi- 
eation  of  lieat  aloiie,  liecaiise  of  tlie  c(ia,i;ulaliility  ot'  tli«_' 
allimneii  contained  in  the  rKpior  (luris. 

Km.  I(». 


I.  I'us-torpusclf!',  frcsli ;  2,  pus-corpuaclus  ttlltT  tin;  uulkjii  of  acilic  ni'lJ. 

Upon  iiiicroseopical  examination  we  di'toot  tlie  iinniis- 
takahle  presence  of  piis-corpiiscles ;  lint  we  must  not  for- 
•rct.  in  examiniiiir  urine  for  pus.  that  the  pus-eorpus*'le  is 
not  always  to  In'  distinguished  from  the  white  lilood- 
corpusde  or  from  the  miicus-ettriiuscle.  In  catarrh  of  the 
liladiler,  however,  no  matter  how  iiuiik  rous  the  mucus- 


y,,i.„,i,ns~.iiui<iiirs  nisHAsn 


78 


,.n  ,i,.....i.-..i  .-min-,,.,..,,  ;''■'",■'';''•;',',,,,,;,, ,1,,;, 

.l"'"ln ntaM,.n,.|..,s.      I   "        "     .n,,;.,.    ,,,„„ 

s,,,|,.  „m.v  .  I.."  ll.     1^",'  .,   „,,  HMv  ,„  1...  mn.l, 

;S::;: "";:"" '"^-: ,„„..>„,„..,. 

sUj^l.t  iVvor.  alHco^scK  that  huvo  ..i-mumI 

'"','     ,    ,     ■  ,1,1  tl,..  .■hlawimnt  «„.n.-."l>Ti»-'  "" 

several  coiirtecutivi-  <lay=^. 


ClIAPTEU    XI. 
I 

NEPIIUIT1.<— IllUtilir's    DlrfKA^K. 

„  .,„.l-,tiiro  „fiulliuiHiu.t..iv  ,hs,.'asw  ,.l  tl..'  M.lii>y«- 
;:  '  ,;„;lw.„l  „o„..n,.la,„.o  „,•  ....  n.,la„nua„.r,  ,hs. 


The 

V 


wm 


I 


/>/va;. ISA'S  or  Tin:  hiD.M-ns. 


caHcs  lit' till'  kiilinvs  i>  im  il.mlit  liiru'flv  iTs|i(iiisili|c  lni'  tlic 
liopflt'Mslv  imli  linitr  iilr:i  ol'  tlic  |>:illiu|n<ri<'iil  riiinliiinii 
wliitli  ilic  trim  iSiiirlii's  <lis»'iisc  tMinvevpi. 

<  Ml  fKiiiiiiciiciiii.'  tlic  stmly  n\'  (lism^ts  ut'  tlu'  k'nliH'V-<  tlit> 
^liuliiil  u^iiiillv  limU  liiiiisclt'  I'lilniiirlcil  in  llic  iiii^Ihs  nt' 
I'liiifiisiiiir  ftTiiH, — siicli  lis  <l(>i(iiiiiiiiitivc  iir|iliriti-i,  |iiinii. 
t'liviiiiiti.o-'  iH'|ilii'it'H,  tiil)iiliir  ii('|)|irit'H,  tiilmlitis,  tiilml 
iir|i|iriti-.  irli'-iKTiilit-iu'iilirili-*,  iiitci'-tifial  iii'|»liiiti-i,  intrr- 
tiilmliir  iu'|ilii'ili-,  iroiity  kiiliU'V,  firrlinsis,  alisccss  ol^tlu' 
k'uliii'V,  iiiiivlitid  (Icir»'iii'ratinii.  waxy  kiiliii-v,  liinltu'cdiH 
kidiifv,  alliiiiiiiiiiiria.  Miiirlit's  disnisc.  liiiul  dixiisc,  iinitf 
niiirlit's  ilis(  asr,  cliniiiic  IJriylii's  discii-c,  iiilaiiliiil  iii'|iliri. 
tis.  iT(iii|M»iis  iifplirilis,  iiiurliiis  llriirlitii,  aciitc  diU'iisc 
ni'|iliritis,  irraiiiilar  kidiu-y,  liTaiiiilar  coiitiiutiiiir  kidney, 
diU'iisc  interstitial  iu'|iliritis,  rtU|tiiurativc  nciiluiti^,  ii(|iliri- 
lis  Vela,  red  i;raiiidar  atiii|iliy,  cniisciiiiivf  Mrii,dit's  dis- 
I'ilsf,  etc. 

It  Would  lu'  just  as  rcasdiialdr,  and  no  nii>rt'  |n'riii(iiiiis 
or  ('(inlusiiii;-.  t(i  use  tlic  iini|iialiticd  tcini  liinu'  Icvcr  i'ur 
all  dist-ascs  of  the  Iniitrs,  liaviiiij  no  definite  terms  t'or 
Itroiieliitis,  capillary  limncliitis,  Iininclio-pneiinioniii,  pneii- 
nmnitis.  or  lihroiis  plitliisis,  as  it  would  lie  to  iipply  most 
ol'tliese  terms  iiidiserimiiiatelv  t(»  aiiv  and  all  inllammatoiv 
diseases  o|'  tlic  kidneys. 

We  liavi'  a  nephritis,  as  we  have  a  piuMimoiiitis,  which 
involscs  in  intlamination  the  entire  oriran,  and  ;ii  either 
ease  terminates  in  recovery,  ahscess,  or  chronic  disease. 

It  is  only  iieee.vsary  to  hear  in  mind  that  i'or  all  practi- 
tical  purposes  till'  kidneys  are  made  up  essi'iitially  of  three 
tissues, — \iz.,  hlood-vi'ssels,  tuliules,  and  interstitial  or 
iiilertuliiilar  tihrous  tissue.  In  one  case  the  lesion  is 
primarily  and  i-sscntially  an  iii/cr.'^lHiiil  t>f/>lirifl.i,  whose 
patholotrieal  con<lition  is  the  result  of  the  hypi'r|ilasia  of 
tlu'  lilirotis  interstitial  tissue  and  itssuhse<pK'";t  eontraetictii. 


>' 


,v/.;/'//w/r/><-/"'"'"'"^  '""''"■ 


<•> 


T .■•■.; ;''■>: ';:;:i;j.i:;r;r;^;*": 

orjrauswl.i.hn ^''''^ '":'';';:,,...  ot' .h.  u.in.., 

'-'-'•f  It::  ;:r  :i"  >-^-- 

,vl,;m..iv..  .x.nmKitlon.  ,.„,.,  ui.i„..y.,  :>s  in 

'"   ''"'  Mo.m.u.latmvuMhsu..  ,.;,„.,  ,1.. 

,1...  of  .li..a.-  ..f  any  <>»»..,•  -^'    ;  '   1^,    , ,„,  ,.,i- 

;r.rr'';^::':;;::ir;:i;;i'.-^;;;:rr,,:;;'';;; 
-;■•- ': ;;"?r  ;,::;;::;:•  :ir;::;;,;:;;l::' ., .,. 

i:;:i;t:::;:^-,. ,,...,..-;.,; - 

(•  iiui  'i^"-  '"^  •  ,   .  I   .,,,,   <i  I  ft'  we  snail   "I' 

„,;'::.::' 'i. "..I.-.- '•'■■■.";" ""■^'"'^■"^ 


I^BMft 


7*i  niSKASI-JS  OF  THE  KIDSEYS. 


W 


CHAPTER    XII. 

TUnULAU  NKPHIUTIS — Tflifl.TTIS — TriiAL  NEl'IlIlITrs — KKS- 
ylAMATIVK  —  CATAUKIIAL  —  CKOUI'OUS  —  ACITK  —  .<115- 
ACUTK — ClIKONIC. 

Aetitc.  tubahir  ncphrilis  may  be  (lofincd  as  an  acuto  iii- 
HaDitiiation  of  tho  tuliiilcs  and  Malpiufliian  oorpusclL's  of 
the  kidney. 

Etiology. — Injuries,  sneli  a.s  l)lo\V!^  falls,  or  wounds,  are 
not  infretiuently  the  cause  of  acute  tubular  nephritis,  as 
are  also  the  acute  infectious  diseases,  more  particularly 
scarlet  fever,  diphtheria,  cholera,  and  erysipelas.  In 
addition  to  these,  there  is  that  mysterious  eliolouii-al 
factor  which  operates  we  know  not  how, — viz.,  catching 
cold. 

Suppression  of  the  action  of  the  skin  is  a  fre(iaent 
cause,  as,  for  instance,  lying  on  the  cold  ground  after 
excessive  physical  exertion,  or  exposure  to  draughts  while 
[lerspiring,  as  is  the  case  with  bakers,  firemen,  and 
moulders,  and  particularly  in  those  addicted  to  the  use  of 
alcoholic  liquors. 

I'yicmia  is  responsible  for  some  cases ;  and  a  constant 
source  of  acute  tubular  nephritis  is  pregnancy. 

Intlamnuition  may  invade  the  kidney  from  other  organs ; 
for  instance,  the  right  kidney  f'-om  hepatitis.  Perine- 
phritis may  be  the  primaiy  trouble,  or  a  cystitis  may 
involve  the  ureter  and  extend  to  the  kidneys. 

At  times,  when  very  hard  pushed,  we  may  be  com- 
pelled to  fall  back  on  our  old  friend  "idiopathic." 

Age  is  a  factor  in  "^he  etiology.     The   great  majority 
of  cases  occur  betweoi  the  ages  of  fifteen  and  forty.     It  is, 
rare  in  children  exce[it  us  -ui  a(!Companiment  or  seouela 


grr.TO'.T.'.taorr  jyt-gBT  ;nav  'TO'*^HK«j:cWa'^'^igUffii''g't"fi«"c:r»^rTi"''^^^^ 


f#^fe«W!JK?>*tii'W>»»«S'«a»a*«r* 


TriilLMt   XKI'Ifh'ITIS. 


77 


TIS — DKS- 
TK  —  .<115- 


iU'Uto  111- 
iUsc'Il'S  ol' 

uiids,  are 
ihritis,  nti 
rticularly 
'las.  Ill 
tioldii'U'al 
catc'liiiig 

frequent 
iiul  at'tor 
ht8  while 
icn,   and 

he  use  of 

eonstant 


r  organs; 
Periiie- 

itis   may 


1)0  eoiii- 

majority 
ty.     It  is, 
[•  sor'uela 


„f  tl.e  aente  infeetious  diseases,  and  is  not  tivim-nt  after 
l,v,  oxeept  in  the  intem,erate  or  in  se^tie  conditions  and 
oX.las;     Males  are  more  sul.jeet  to  It  than  toinalc. 
,,,;.i,  .  ,,.,th  to  their  hal.its  and  to  their  oeenpations.     In 
n  oahMneiit  of  the  fui.etion  of  the  liver  the  elnninatK.n  ot 
;;:;,iary  salts,  a.d  elements  the  result  ..  ine..n^^ 
tissue-metamori.hosis  not  iiifre<iuently  pn»vokes  a  tidn 
Nephritis.     This  may  oec-ur  also  where  the  ki.lney  is  ealled 
UDon  to  eliminate  sugar. 

'  Aeute  tuhular  nephritis  is  met  with  in  all  el.niates  but 
,nore  tVeHi.eiitlv  in  the  eold,  .lamp  months  <n  the  year  tl mil 
the  wirm  summer  months.  Syphilid  is  responsible  h>r 
some  <-ases.  Tvson  has  been  nuoted  as  saying  that  nienta 
anxiety  resulting  from  grief  or  from  business  or  finaneial 
embarrassments  may  cause  IJright's  disease. 

That  anv  man  broken  down  by  cares  and  anxiety  might 
d..velop  Brioht's  disease  is  not  surprising,  nor  is  it  un- 
u  I  stJange  that  mental  anxiety  should  bo  the  remote 
cause  of  disease  of  any  organ.  The  same  cause  will  p.o- 
duee  dittorent  diseases  in  ditferent  individuals  according 
to  their  respective  diatheses.  ^    ,         -,  ^ 

Only  a  few  years  ago  Dr.  Sommola,  of  Naples,  advanced 
the    lL>ry  that  nephritis  is  a  blood-disease ,  and  tln^  tlie 
i,nary  cause  of  every  case  of  albuminuria  is  ui  the  blood 
Tl  at  it  i.  the  pathological  chemical  condition  of  the  bhM  I 
w  leh  irritate;  and  intlames  the  tubules  is  true ;  but  it  this 
morbid  condition  is  produced  by  the  suppression  of  the 
f^netions  of  the  skin  or  the  liver,  I  do  not  see  how   h 
blood  condition  can  be  called  the  priinary  cause.    I  bo h  vc 
it  was  I)r   C.  Letzorich  who,  several  years  ago,  first  dc- 
Libed  bacteriological  nephritis.     He  had   one  season   a 
hirge  number  of  cases  of  nephritis  in  <^^^^^-;;^:^  ^^ 
whom  had  had  an  ac-ute  infectious  disease.     They  al    ex- 
hibited similar  symptoms,  and  ia  every  case  h.    ound  .... 


^hwtnsMs^ 


«»it.'it*»w.6aK.-. 


7S 


nisi:.is/:s  or  the  kidseys. 


siimo  liiU'ti'ria  in  tlii'  uriiu'.  Dr.  Lctzn-ich,  if  T  ri']iu'inl»or 
rii^litly,  looked  iiiion  tlie  disciisi'  in  thcso  cast's  as  an  cu- 
(k'liiic  condition,  tlii'  particular  bacteria  Imvinj;  ,uaincd 
access  to  the  blood  tbrotiiili  the  niediuni  of  drinkinir-water. 
It  lias  lonj;  bei'ii  noticed  that  a  sliu;lit  amount  of  albumen 
cften  occurs  in  the  urine  durinu;  an  attack  of  erysipelas; 
while  in  many  instances  it  is  accompanied  l)y  a  more  or 
less  severe  attack  of  acute  tubular  nei)hrit".s. 

Moulin  in  his  recent  AWU'k  on  snrsiery  instances 
Bri_u:ht's  disease  as  an  etiological  factor  in  erysipelas.  To 
be  sure,  gouty  people  with  cirrhosis  of  the  1  idney  often 
contract  erysipelas,  but  in  the  many  coml>incd  cases  of 
ervsipelas  and  acute  tubular  nephritis  that  have  come 
under  uiy  notice  I  have  alwiys  considered  the  former  the 
cause  of  the  latter,  either  as  the  direct  result  of  the  ]»res- 
ence  of  the  Stirptococcits  eri/sipdatosus  in  the  blood-vessels 
of  the  kidney,  or  indirectly  from  the  chemical  condition 
of  the  blood  due  to  ptomaines.  The  bacteriological 
etiology  of  tubulitis,  however,  will,  I  an'  fully  convinced, 
be  found  to  api)ly  eiiually  well  to  the  nephritic  iniiamnui- 
tion  that  accompanies  or  follows  any  of  the  other  acute 
infectious  diseases.  Aside  from  the  micro-organisms  of 
the  acute  infections  diseases,  whether  special  nephritic 
bacteria  will  ever  be  discovered  is  a  matter  for  the  future 
to  decide. 

The  etiology  of  the  tubular  nephritis  accompanying 
presinancy  is  oljscure.  Some  writers  consider  the  pressure 
of  the  gravid  uterus  upon  the  kidney  responsil)le  for  the 
trouble.  I  have  seen  nephritis  and  dropsy  as  early  as  the 
third  or  fourth  month,  certainly  before  the  uterus  had 
attained  a  size  sufficient  to  exert  any  pressure  upon  the 
kidney,  tlius  leaving  us  to  look  for  other  causes  to  account 
for  the  intfammation. 

Other  writers  have  suggested  the  possibility  of  the  in- 


-'VKSiJaii^£S:?)Xaeau^. 


«iiAJJi!^-«*---^-*--'-*^'  ■ 


TUBVLAR  NHI'lllUTIS. 


79 


iis.     To 


fl.nnuatu,u  boinj,  th.  rosult  of  vuss.vo  -»^-^- 
,.,,,s.u.v  oftlK-  .,n-avi.l  utorns  on  tl..  n-nal  vcu.s,  !>„>  ,.H- 
.  .ntin.-  tho  .vturn  <.f  I.I00.I.  A,.un,  tl.e  theory  has  h..n 
^dvu.:;^  that  iTossuro  upon  the  ureters  may  he  an  c.,o- 
htieal  ta.tor.  Exactly  how  ohstruetu.u  ot  the  u  ete  . 
.;uhl  disarrange  the  kidney  without  l'-*--^;;;^'  j;;^ 
and  .,n-eat  pain  from  pelvie  diste.mon  it  ,s  d.theult  to  coin 

''t::L  plausible  theory  is  the  one  whieh  su,,ests  that 
V,re.suro  upon  the  iliac  arteries  or  the  ah.  ounnal  ao.ta 
"p,'oduc  n,  an  intense  hypenenna  of  the  knlney,  cause 
he'  Ihununm-ia.     We  nu.st  not  tor^et  that  n,  s..n.e  cases 
\„„„,,„,,i,  durin,  pregnancy  there  .s  a  l--'>;l'ty;  * 
nenhritis  havin.^  been  present  before  the  women  became 
;^^^     and^his  suggestion  is,  I  believe   strengthenc^ 
^y  Ihe   l^tthology,  as  we    occasionally  hnd  m   cases    ^ 
won.en  who  have  died  in  puerperal  convuls.o.is    he  ^nall 
TvhUe  kidney  or  the  atrophied  v  hite  kidney  ot   chronic 

"i:tr^:U>le  that  the  kidney  c.mld.nle^ 
chan.res  in  so  short  a  time  ;  and  hence  it  is  almos  crtain 
ma  hi  these  fcw  cases,  at  least,  the  w.>men  had  .dbuminu- 
^a  bet<,re  they  became  pregnant  K  the  women  were 
.ninipara.  they  had  probably  had  albunieiyv  .tl  hur 
previous  pregnancies,  and  the  kidneys  had  tailed  to 
recover  themselves  during  the  interim.  ,,.,,' 

ThoiKdi  there  is  no  absolute  proof  of  the  hypothesis,  the 
.t..on..  probabilities  are  that  puerperal  nephritis  is  gener- 

d  V  ff  not  always,  the  result  of  the  profound  bl<,od-change 
that^  occur  duHng  pregnancy,  especudly  the  nicrea.     o^ 

extractive   matters  with    the    general    increased    hcart- 

'^S:S;?:?1^:  ""^"^-  ^«..-The  etiohjgy  of 
subacute  tubular  nephntis  ditlers  in  no  way  from  that  ot 


so 


DISEASES  OF  THE  KIDSKVS. 


the  acute  t'oriii.  Tt  is  only  in  tlu-  cliiiiciil  history  tliat  we 
tiiid  ii  difi'crt'iict",  it  l)oiii<r  iiioiv  insidious  in  it»  invasion. 

A  larifc  nninlitT  of  casi's  aro  associated  with  cirrhosis 
of  till'  liver  or  with  aiiy  form  of  chronic  hepatic  disease 
which  distnrhs  the  fnnction  of  the  liver. 

Etlnloifi/  iif  Chronic  Tahnhir  Nephritis. — (/hronic  tnbnlitis 
is  simply  the  result  of  acute  or  subacute  tulnditis. 

]'.\Tii()Lu(iV. — In  acute  tubular  nephritis  we  find  a  lartje, 
smooth  kidney,  in  most  cases  red  in  color,  the  eidar<;e- 
ment  confined  chiefly  to  the  cortex.  The  caiisule  is  easily 
detached.  The  microscope  reveals  tlie  fact  that  the  puth- 
oloirical  change,  except  the  hypera'mia  and  the  serous 
exudation,  is  confined  entirely  to  the  c]»ithelium  lining 
the  tubules  and  Mali»ii>liian  corpuscles,  with  more  or  less 
involvement  of  tlie  eiulothelium. 


Fig.  11. 


The  epithelium  will  be  cloudy  and  swollen,  from  the 
al)sorpti()n  of  the  exuded  albuminous  fluid,  and  may  be 
granular,  from  the  infiltration  of  oil-globules  and  detritus 
partly  exuded  from  the  blood-vessels  and  partly  the  result 
of  destruction  of  the  epithelial  protoplasn        jlf. 

In  a  more  advanced  stage  the  epithelium  has  a  coarser. 


!t>  ««ii»MBwna:t«><aicaff'W8»  ii-miwaBi«cs*h  -■ 


Ti'iiUi'Hi  sErimiTis. 


«l 


:::L:"not  involve.l,und  the  bU><.,l-ve..cl.  ronuun  un- 

^'^Xd;..-ln  .nbacuto  tubular  ncphnti.  wo  om.  W 
.V  U.ht-folorod  or  the  .,M-alU..l  white  kidney.  I  he  cap- 
^ullr^Irip.  easily.     The  epithelhun  is  swollen  and  granular, 

-VZl^:ZZ!:'o^  ehronie  tubular  nephritis  . 
von-  h  ^0    whence  it  is  usually  called  the  large  white 
^hie^     Th^  capsule   is   easily  detached,  the   cortex   is 
t    ".enlarged,  the  endothelial  cells  are  swollen,  an<l  most 
r  h  "q  tlieli^m  is  de.piamated.     The  cast,  found  in 
t.  tubeiand  urine  are  of  the  hyaline  variety-.     An  exc.,.- 
tn   n  W.e  is  apt  to  occur  in  the  chronic  tubu  ar  nephriti 
o   th    in"  mperL.     The  kidney  is  ot^en  small  in  size  am 
r  d  iu  color,  the  reduced  size  of  the  organ  being    he 
lu  of  an'atrophy,  not  of  a  e-trac^ion.    W  ere  the 
disease  is  of  long  dur  xtion  there  is  a  slight  thickening  of 
the  interstitial  tissue  and  of  Bowman's  capsule. 

SYMPTOMS.-Acute  tubular  nephritis  is  generally  ush- 
ered   n  by  a  chill  or  recurrent  chills,  which  may  no^^  be 
^:;     ver'e,  followed  by  fever,  the  temperature  not  ike 
o  "be  over  102°  or  103°  F.,  and  accompamed  by  heaxN 
.Chi  M-ins  in  the  back,  which  extend  around  the  groin 
::^^  it-t  n  down  the  ureters.     There  is  frequent  inictu    - 
In   with  the  passage  of  a  small  quantity  ot  urine.     The 
H^i    high-  olored,  of  high  specific  gravity,  and  con- 
^n^lbun^n,  a  lessened  quantity  of  urea,  aiid  ..netm.^ 
blood-corpuscles.      The  patient  is  usually  troubled  with 


iii 


82 


/)/.s7;.i.s7;.v  or  the  kidsevi^. 


i 


iiauscii  and  v<)mitill,i.^  and  is  soMom  witlumt  sowit  lioad- 
aclic.  This  (•(.lulitioii  may  last  for  two  or  tliivc  days, 
wJHMi  tlu-  uriiu'  iiKTcasos  in  (unmtity,  Ix-ronu's  of  iowiT 
spoc-itic  frravity,  tlu'  Idood  disapiK-ars,  tlic  pains  ocasf,  the 
temprnitniV  fidls  to  100°,  vonntini,'  diniinisla-s  or  c'l'ascs, 
and  tlu'  iR'adarhe  subsides. 

Voinitinji;  is  a  tivtiue-nt  symi.tf.ni  in  allmniinnria,  and 
its  si'Vi'ritv  often   sucnis  to  bo  in  dircH-t  relation  to  tlio 
olifiuria.    '  This   well-known    tendency   to   voniitin.i;    in 
nephritis  is  often  attrihnted  by  writers  to  retlex  action. 
Tt  is  most  probably  dne  to  one  of  two  canses,  or  in  >:(.nie 
cases  perhaps  to  both:  first,  to  the  fact  that  the  .ixastric 
secretions  are   deficient   especially  in   free   hydroc-hloric 
acid,  in  consequence  of  which  the  food  fails  to  be  diirc.sted, 
and  produces  irritation,  pain,  and  vomitini;;  secf)ndly.  to 
the  elimination  by  the  mucous  membrane  of  the  stomach 
and  bowels  of  waste  material  whii-h  should  be  eliminated 
by  the  kidneva,  just  iw  in  gout  patients  so  freciuently  stitter 
from  severe ^ittacks  of  vomiting,  diarrha-a,  bronchitis, 
a-sthma,  or  cvstorrhrea. 

In  the  latter  of  these  cases  it  is  no  doubt  owing  to  the 
elimination  of  urate  of  sodium  by  the  respective  mucous 

membranes.  .    •    e    *- 

AnaMuia,  we  have  seen,  is  one  of  the  characteristic  ti'at- 
ures  of  acute  tubular  nephritis.  Whether  it  dei.ends  upon 
deficiency  of  digestion  and  assimilation,  or  whether  the 
diminished  gastric  secretion  is  owing  to  the  ansvmia,  is  a 
cpiestion  of  importance.  The  auicmia  of  acute  tubular 
nephritis  is  probably  a  primary  condition  of  the  blood, 
and  the  <liniinished  gastric  secretion  the  result. 

For  some  not  very  readily  explained  reason,  we  often 
have,  accoinpanviuii  these  symptoms,  <vdema  about  the 
face,  particularly  under  the  eyes,  and  after  a  few  days  the 
anlema  may  also  appear  about  the  ankles. 


»'rRlS»»M»»*»il»>eSW!a 


i;.«,»ftW«Mfcn>K»«SS«iS«-»y?''S»»«»'»'»*'»*'™^^ 


TUnVLAR  SKPIUdTIS. 


h:\ 


In  ..tl,or  oaso.,  wLiU-  tl.o  lusuhu-h.  in  a  HH-.sun-  suh- 

,  isai.lK'U.-s,  l.ut  tlK«  all.ui.uM>  lurmis.s.      11.  l-ati-ut 
r^r     l-mUu..     Thoc.on.mion,nay,.o,aa,ntln.U>r. 
levoral  wod<s  ..r  inonths,  an.l  .lisaH-oar  cnturly,  <.r  the 
h   ,    V  may  .teadilv  incroas.,  the  a.uonnt  .>t  all..u.u.n  oon- 
H      •    .    bout  the  ;auu.,  while  earetnl  cxanunatu.n  hy    he 
L..:.o,e  will  reveal    tul>e-.ast.     n    ahmu^^^^^^^^ 
C.ithelial,  irranular,  and  fatty  varieties       I  he    -.  tu  ntj  t 
omu^s  j^nvdually  more  aiuemie,  or  rather  the  l,loo,l  may 
he  said  to  he  in  a  hydraMiiie  i-oiidition. 

With  droi.v  of  the  lower  extremities  there  may  he 
,,,„,,  „t-  the'whole  eellnlar  tissue,  or  general  anasarca, 
with  effusion  or  aeeumulation  of  tiuhl  in  tlie  serous  eaM- 

cvhlent,  a  t^al  termination  may  oeenr  from  u.lema 
!^  .U  ,  ..dema  of  the  lungs,  or  ett^.sion  intc>  tlu-  pleural 
c  ^  V  <>•  the  ,eriear,lium;  and  when  so-ea  led  uneini 
^  !nun.,  eoin-ulsions,  or  eoma  oecur  in  this  hu-ni  c. 
Brh^ht's  disease,  it  may  he  due  to  oedema  ot  the  h.am  or 
effusion  into  the  ventrielcs  or  subarachnoid        _ 

There  ib  seldom  disturbance  of  vision,  albuminoid  i  ti- 
„iU:  or  epistaxis  in  this  t^.rm  of  Bright's  disease.  In  the 
"wases  where  dimness  of  vision  occurs  it  iB  due  to  ii. 
terference  with  the  optic  centres,  and  not  to  any  lesion  of 
the  (.ptic  nerves  or  the  retina. 

On   the   other  hand,  the  patients  are  very  subject  to 
pericarditis  or  eiidoearditis,  an.l  pneumonia. 
^    S,.>nto.>,s  ofSaharnte  yV/../;//..-The  symptoms  in  what 
I  ;ro  >ose  to  describe  as  subacute  tubulitis  differ  from  th<,se 
of  the  acute  form  principally  in  the  first  stages;  for  in- 


o-4*e^rt*.«E*«B&si*' 


itfWW 


84 


nisi:.isi:s  or  the  Kinsins. 


f  .'^ 


wtaiict",  it  is  not  iislHTfd  in  liv  diills.  tluTi'  is  no  t't'VT, 
tlicn-  \vYv  no  iiciiin.tr  I'ains  altont  tlu-  loins,  iind  tlicir  may 
1(0  ncithrr  nausea  nor  voniitini;  lor  wt'cks.  I  lau'L'  liad 
Buvcral  such  iiuticnts,  JK-ru'viiiir  tlu'insdvcs  iiortW-tly  well, 
who  have  |>nsente(l  themselves  for  examiiuition  for  life- 
itisurance.  rpou  examinini;  the  urine,  a  lariTc  (juantitv 
of  alhumen  is  found  to  he  jtreseiit.  On  careful  iiH|uiry 
ono  may  elicit  the  fact,  wliich  the  individual  had  not 
!iotic<'d,  that  micturition  has  heen  a  little  more  fre(|Uent 
than  formerly.  Tf  the  microscope  in  such  cases  shows 
tuhe-iasts,  ejiithelial  and  ,<;ramilar,  or  if  tho  quantity  of 
alhumen  is  too  threat  to  he  accounted  for  hy  the  so-called 
physiolojrical  alhuminuria,  these  patients  will,  within  from 
six  to  twelve  months,  hecome  anaunic  and  dropsical.  In 
fact,  the  later  syitiptoms  of  acute  tuhular  neiihritis  will 
hecome  evident  here. 

Many  of  these  patients  consult  the  physician  I'or  head- 
ache, and  perhaps  for  nausea  or  indiirestion.  They  may 
tell  him  that  they  have  consulted  several  physicians,  whose 
prescriptions  have  failed  to  u'ive  them  relief.  If  these 
symptoms  are  of  several  months'  standinir,  tlio  jtatient  may 
also  complain  of  some  dyspnrua  or  weakness,  and  there 
will  he  more  or  less  anorexia,  hut  no  complaint  peculiar 
to  the  urinary  or<;ans. 

Careful  examination  and  inquiry  may,  in  these  cases, 
a.irain  elicit  the  fact  whidi  the  ^latients  had  failed  to  no- 
tice, that  micturition  has  heen  of  late  somewhat  more 
frequent  than  usual,  they  prohahly  jrettinjj:  up  once  during 
the  night  to  emi»ty  the  bhulder.  Such  patients  seldom, 
however,  fail  to  exhibit  a  jieculiar  cachexia,  which  I  have 
heen  in  the  hahit  of  calling  the  "kidney  expression." 
It  is  not  the  smoky,  dusky  look  of  pneumonia,  nor  the 
cyanotic  appearance  caused  hy  valvular  insufficiency,  hut 
a  putty,  doughy  appearance  peculiar  to  these  cases.     The 


t'  3«j«!B»<sa!«!«!aBa»)W»*ft«f«««Sfe«WK*»  - 


.•,.wt■S!■^^^^i>i^»ig^»^^g<g 


TViiirMi  MirimiTix. 


85 


uTf  iiiiiy 

iiu'L'  hat  I 

•tly  well, 

tor  lit'i"- 

(|iiimtit_v 

1  iii(|uiry 

liiul    not 

t'rc'((uc'iit 

LS  shows 

aiitity  of 

so-called 

thin  iVoni 

<'u'al.     In 

rhis  will 

lor  liead- 
riii'V  may 
us,  whose 

If  these 
tient  may 
xnd  there 

peculiar 

ese  cases, 
led  to  no- 
hat  more 
ce  during 
ts  seldom, 
ich  I  have 
pression." 
ix,  nor  the 
iency,  hut 
ises.     The 


,,,,,,,,,  .Kaminati.>nJnvarial.ly  sh..v.tluMMvs.u.e.d^^ 
,  p.;an.ount  wt^dl.nnn.n,  with  tlu- n.nal  .as  >  .     - 

•  ,  1  „l,l  tJ...  ."He  i.ro>rress  untavonihly,  theie  \\  HI 
„,,,ths.  should  the....  .  ,„,,..,..   o.dema  of  the 

he  droi.sv.  anasarca,  a-eite.,  an<i  ptiu-i 

,,.J...\.,lnsion  into  the  pleural  eavuy    as. e 

riHdy  seen,  ditlering  in  no  way  fron.  the  la.e.    >ta,.  >  ot 
the  acute  t^n-n..        ^,v,/.-;//..-Then.   i.  no 

anasarca,  I  usually  designate  as  cases  ot  elnon.e  tubulai 

"tlnv^^f  these  cases  live  t;.r  one  or  two  years,  and  oc.. 

.h.nlv  a  case  of  evide.xt  tuhular  nephrit.s  may  live  es en 

°''i;:;t::n,.„p.v  U  so  c„,.s..nt  .  eon,Utu,„  i,>  ...e  acute 

•"^:r:n:::"^;op,.  .f ...« .«..  ^x..™m.,  ™i 

n  cltos  from  iwrtal  oLstmcfmn,  a»  in  i'.n-li..s.s  ..  .amir 
^nt  W  the  ar„,«y  i»  clue  ...  oolla.eral  l,l,,.,l-i.,y».m-e 
rthe  V  iu,whne  tl»  ,U.,.,,v  of  Bright-.  ....-•  -  ■ll- 
JIt  her  to  a™tho..enic  eon.lition  of  the  hloo,l  or  hh.o.l- 
;l:rbrou;*t  aSout  by. he  elu„i„a.io„  of  all,u„.e,>  or 
thp  roteutior  of  uric  acid,  etc. 

The  e-ai>e  of  .er„,u  iron,  the  hloo,l-ve.HeU  m.o  the 

8 


.iwUMIIwMli'i 


^  t^fSi^^i^^SS' 


m 


DISK.ISF.S  OF  Tin:  KinSFAS. 


oilliilur  tissm-  irt  a  tniiisddation.  ii  iin-iv  i-liysical  or  ii»"- 
cliaiiical  i.n.fc-ss,  whicli  lakrs  placr  I'n.iii  tlu'  rapillarii'.-A 
into  thf  iiitiTsticfs  of  till'  .•(.'llular  tissiu"  tastiT  t!iaii  it 
,.i,ii  l.c  talon  n|.  I.y  tlir  vfiiis  and  Iviiiphatics ;  diiri-rin^^ 
fiitiri'ly  tVoiii  tlu-  i-xiidatioii  of  iiitlaiinuation,  which  in 
a  vitai'i.i'oi't'^s,  the  oscain-d  lluid  hoin.ir  capahlf  of  organi- 
zation. . 

Whatever  the  |.atholo,<rifal  condition  .(f  the  IiUumI,  it  is 
clcarlv  not  a  mere  ana-mia  or  hvdra'iiiia. 

Dropsy  is  often  a  syinptoni  of  diseases  of  nntritit.n  and 
the  l.looil  .ijlandnlar  origans,  hnt  it  is  never  iireseiit  in  the 
exti-i'ine  (U'lrpee  in  which  we  find  it  in  these  cases. 

A  peenliarity  of  the  dropsy  of  Hri-lifs  .lisease  is  its 
tun.lency  to  shift  ahoiit,  a  ciivntnstance  that  is  dithcult  to 
understand.  With  the  exception  of  the  pefit<.neal  cavity, 
all  the  sei'ons  cavities  are  more  likely  to  till  in  Bri-hfs 
than  in  any  other  disease. 

Freqnen'tlv,  in  Uriirht's,  we  find  the  dropsy  .lepend- 
injr  api.aivn'tly  upon  the  secretion  of  urine.  When  the 
urTne  is  scanty  the  dropsy  develops  more  rapidly,  disap- 
pearinir  in  a  measure  when  the  kidneys  act  freely.  1  h .w- 
over,  a"t  other  times  there  may  he  extreme  dropsy  with  a 
free  seeretion  i)f  urine. 

The  condition  of  th(^  arteries  in  acute  Brii^ht's  has  not 
received  from  mic-roscopists  and  histologists  the  attention 
the  subject  deserves. 

Xoainhitious  student  of  medicine  need  feel  discouratred. 
There  are  pleiitv  of  discoveries  yet  to  he  made  in  every 
departnu-nt  of  iuedieine,  especially  in  the  etiology  and 

patholo'i'V  of  disease, 

rROONOSls.— Time  was  when  the  proirnosis  ot  albu- 
minuria iTcnerallv  was  held  to  be  much  more  lun'oless 
than  at  present.  The  name  Bright's  disease  has  a  great 
terror  for  the  laity.     I  am  surprised,  in  the  light  of  my 


.-.^»a.v  ,r^rfia»*«S*itfefciia)«tWHr*^^ 


i«ii(Ul6»l»ei«««*^'^*^ 


Tfitri.An  sKi'iih'iris. 


87 


,1  (ir  lu"- 
ijiilliirit'H 
t!iini  it 
ililli  rintr 
,vliifli  in 
f  ufii'imi- 


m1,  it  is 


CM 


itidii  aiitl 
lit  ill  tho 

isL'  is  its 

ilHrnlt  to 

ill  cavity, 

Brinht's 

■  (li'])fii(l- 
Vlu-n  till- 
ly,  (lisai.- 
y.  lldW- 
isy  with  u 

's  has  not 
attention 

oonrntco(h 

0  in  vwvy 
L)lt»i>'y  and 

1  of  alhu- 
i  hopeless 
las  a  _i!;reat 
jht  of  my 


,  1 :     .  .lie  ,io ...  r......  .......|.ii.-';-..  •■'";'.•'""■;;;; 

;;;';;t,:r;;:^:;:'::;;^r:i,,;i::r;:^:;:;i 
'1.::: ::;:::';--., .::«'' n....  ,„.........-; -- 

n    we  h'lve  no  spe-ilie  in  nie.lieine  that  will  aeeon.,.1.  h 

r  W-^u  ,  however,  in  a  nieasnre,  relief,  the  patu.it  s 

luLs^^uia  .:inH.al  to  the  .cin  and  howels  to  assist  m 

(loin-  the  suspended  work  ot  the  kuhieNS 

Absolute  i-Lt  is  to  he  eiMoined,  with  the  siniphstd 

.on.isti...'  <.f  milk  and  water  ov   ruHMvater.     l)i>-cnp 
n^   ^applied  ..ver  the  rejxion  of  the  knlneys,  a.so  hot 
""oM  applications,  whichever  is  more  a,reeahle  to  the 

^^Thf  howels  should  he  kept  freely  open  hy  a  saline  ea- 
thn-tie   and  diaphoresis  should  he  insured. 
'  ir^,r    estorU  the  tixneti<ms  of  the  kidneys,  some  .i^ 
vise  d  uretics,  while  others  advocate  the  seenn.n^  as  nea.l.> 
:r;^  mo   complete  physiological  rest  ibr  the  knlnoys. 


"  ^Mftft^^H'tCU  ll*ii^/#0'^&*!^ 


±^ 


HH 


niSH.iSHS  nr  Tin:   KIDXHtS. 


I    licliiVi'    till'    Inif    fdllisc    lies    l>(l\\c»'i|    tllfsc    t\\(i    i\- 

trtiiiis;    tliiit    is,    lii'twt'cii    stiiimliiliiii;   tlif    kisliu-v-*   liy 

fliliri'tifS  nil  tlic  nlic  lllltul,  IIImI  fllt'nicillir  l'Olll|il(tc  |p||\>i(i. 

loi^ical  rvM  oil  tlii>  otlicr.  I  att('iii|)t  to  ki'fp  up  Hoiiif 
li|on(I-|irt'ssiiiH'  oil  tlic  kidiifvs  with  ih  little  irritation  to 
tlu'  oi\ij;aiis  as  [lossililc,  so  tliat  wliiK-  I  eii_joiii  n-t,  rnrorri' 
tlu'  Htrifti'st  r>'j;iim'ii  as  to  diot,  aitpciil  t<»  the  liowils  and 
skill,  and  take  advantat;*'  ol'  fxti-nial  application^  to  re 
licVt'  colinrslion,  I  endeavor  to  keep  up  the  hlood-pvessiire 
in  tlu-  kidneys  l>y  ullowiiiir  the  patient  lari;e  (|iiantities  of 
eold  water  or  rice-water. 

As  the  lessfiied  (|iiantit_v  of  urine  must  depend  in  a 
iiu-asiire  on  the  oi»struction  of  tin'  tiilniles  \>y  easts  and 
cNudatioii,  it  would  seem  reasonahh'  to  suppose  that 
iilood-pressure  kept  up  in  thi'  ijlonieruli,  without  irrita- 
tion, would  assist  in  cleariiiij  the  tuhules.  ff  iiiort-  ai^reo- 
nhle,  tlu-  patient  may  take  carltoiiizcd  or  mild  mineral 
water,  sueh  as  Xapa  soda,  Coronado,  TJartlett,  t'te. 

Here  let  iiie  sav,  /»//•  jxifi iitliisi\  that  if  praetisini;  on 
this  coast,  when  you  do  use  minerul  water  you  should  hy 
all  lucans  ^ive  the  preference  to  the  spriutfs  of  California, 
as  their  varii'ty  is  Icirion. 

In  the  majority  of  cases  a  few  days  will  hrinir  relief  to 
till'  patient.  The  lii'adache  or  vomitinir,  if  iircseiit,  hen'ins 
to  yield,  and  the  t|uantity  of  urine  soon  increases.  It  no 
Ioniser  coiitaiu.s  l»l(»od,  hut  ii  large  amount  of  alhumi-n  is 
still  present,  with  lessened  urea  and  ahundant  epithelial 
tuhe-casts.  The  diet  may  he  i^radiially  increased.  The 
indications  for  appealing  to  the  skin  and  bowels  are 
less  urgent,  and  we  shall  soon  find  our  jiatieut  becoming 
ainvmic,  tor  we  liave  already  seen  that  where  there  is 
much  albumen  there  is  disintegration  of  red  blood-cor- 
jiusdes  and  a  consetiuent  bydriemie  condition  of  the  blood. 

lu  tliis  stage  of  the  di-sease,  tluit  is,  when  the  acute 


.;.»»»(-;■.-  OT*»i«£!Si.!iS5»W!i.Hf.-"=.*swe»fl»a!o-  ^m^m .mm»»e*mmsiiie:-. 


^%. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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O 


s^  ^^ 


7^ 


1.0 


I.I 


l^|2£    12.5 
1^  1^    ill  2.2 


t  u&  1110 


1.8 


11.25  illU   IIIIII.6 


V 


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Photographic 

Sciences 
Corporation 


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^Mi 


L<? 


&. 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICIVIH 
Collection  de 
microfiches. 


Canadian  institute  for 


Historical  Microreproductlons  /  Institut  Canadian  de  microreproductions  historiques 


f.mm!»<^iS^^!i^^sm^f^%^^^i^i^^^^^^'^i^^''^^-  i 


Ti'iiirM!  .\i:riniiTis. 


89 


tVbrik-  svniptnms  liiuv  .lisair'^»T.l,  ..r  in  sul.u.M.tr  cases, 
MiiM  (liilivtu's,  with  or  xvithout  iM-q.anitini.s  ut  in.ii,  srcii. 
t.)  U'ssi'ii  tlu'  .iiiaiitity  of  iill>miic-ii. 

I  luivi-  sfcii  p.arkvMl  in.i.n.vci.U'Mt,  in  Ifssmui-  tl.c 
,,,uu.titv  ofall.nuuM.,  rostorin-  tl.c  apiK'tit.",  ami  anvstiiig 
tlK'anii'mia,  from  tlie  admiiiistnition  ..f  oiu-  or  otlior  ot 
tlu'  following  formula': 

B    Li(i.  !ii>i'iiiri  clili'viili,  ."^i; 
Tiiiit.  firi-i  clilMii.li, 
Spl.  itli'Ti-  iiiiio-i,  iii'i  giv  ; 
(ilvctM-iiii  lul  ^iv.— M. 
Si.,r._.V  tcispoonful  in  wiitn-  adw  viwh   mcml,  iitxl  ,it  iH'dtiin.'. 

In  some  cases  1  in-oscrilK-  only  one-half  drachm  of  tho 
li,.„„r  arscnici  chlori.li,  giving  a  teaspoonfnl  in  water 
everv  two  hours  during  the  day,  occasionally  either  add- 
iu.'  to  this  or  substituting  foi  the  arsenic  one-hali  gram 
of^hydrartrvri  bichloridum,  and  sometimes  I  give  the 
hydrargyr'rhiehlori.lum  alone  in  doses  of  ..ne  one-hun- 
dredthOf  a  grain  every  hour  or  two. 

In  addition  ro  its  containing  the  iron  which  is  so  neces- 
<.,rv  a  "-reat  advantaire  .>f  the  tincture  of  chloride  of  iron 
is  that  it  supplies  the  .loticieucy  of  free  hydrochloric  acid 
in  the  gastric  secretions.  The  a.Mition  of  the  arsenic  and 
bichloride  of  mercury  prevents  the  decomposition  ot  the 
food  in  the  alimentary  .-anal,  and  the  otfensive  ..dor  ot  the 
evacuations,  so  often  present  in   IJright's,  is  comi-letcly 

Aiiother  favorite  prescription  of  mine,  an<l  one  that  will 
perhaps  bo  more  ot>en  of  benefit  than  any  other  that  I 
have  tried,  is  the  following: 
B   Sulphur,  pr.ecipitiitum, 
FiTi'i  c'nrbi)natis, 
Glyc'Tini,  Afi  giv  ; 

A<Juii>  ciiitmin.mii,  vd  iiqusD  copnibii',  .^iv.— M. 
Si-  -A  tcHspoonful  every  two  hours,  or  after  meuU  and  at  bedtime. 
=      ,  8* 


•M) 


DISHASKS  Oh-  THE  KU).\i:ys. 


Tlic  in>i<  i-^  iiurwiit.'d  by  the  aiuiMiiiii,  l.ut  the  hfiu'ticial 
ivsults  iin'  nut  i-ntiivly  .lu-  t..  the  iron,  as  tlu-so  imtionts 
,1.)  iK-ttiT  wli.'n  it  is  fon.l.inf.l  witi.  the  snlplnir.  It  is 
jiossiliU-  that  it  arts  luMU'tirially  on  tin-  nincons  nicnil.rano 
<,f  thr  l.(.\vi-ls  l.y  tlu"  elimination  of  inorhitir  niatrrial. 

Thr  following!:  is  anotluT  mixturr  wliidi  iti  subacuto  or 
rhionir  tnl.ular  lu'iiliritis  is  often  i?ivon  with  hunotit : 

li   Aciili  urscniiwi,  nr.  \; 
Forri  iiirimimtis,  ^\ ; 
IJiils  .(ipiiitiaj  (in-p),  3>— ^'^ 
Div.  ill  ciiiisiilii-  11!'    XXX. 
Si.^r._()nc  ut'liT  <ii'  li  "ii'i'l.  i">'l  »'  '"■•lliinp. 

Thoiv  arc,  of  coursi-.  many  other  comhinations  and 
iMH.i.arations'of  iron.  When''r  have  any  sus,.ieion  of  a 
HVi.liilitie  history,  I  always  prefer  the  tbllowinir,  whieh  has 
served  an  admirable  jinrpose: 

li    Hydnii-','.  liiiiitulidi,  i;r.  ss  ; 
Piit!i->ii  iodidi,  ^>^ ; 
S\  r.  iV'iri  iiMlidi,  ;5i:i ; 
Aiiuii'  dolilliitiu  lid  ^iv.  — M. 
Sig.— A  u■ll^ll."'ll^ul  every  two  hniirs.  in  wiitiT. 

Tn  many  eases,  however,  there  are  symptoms  and  eom- 
pli,-ations\vhi<-h  we  must  treat  as  oeeasion  r»«(iuires.  The 
dropsv  often  becomes  so  ur^'ent  that  it  demands  immediate 
relief."  The  general  anasarca  is  extn-me,  while  some  one 
„f  the  serous  cavities  may  also  contain  ai  larirc  amount  of 
flnid.  The  more  acute  the  case,  the  less  likely  are  we  to 
obtain  diuresis,  even  if  stimulation  of  the  organs  is  jnsti- 
tied.  We  have  then  to  di'i)en<l  on  elimination  by  the 
alimentarv  canal  and  the  skin. 

.\<  for  ".liuretics.  onlv  the  mildest  should  ever  be  used 
in  acute  tubular  nephritis.  When  the  very  acute  symp- 
toms have  passed,  I  often  prescribe  the  following  pill : 


I 


^iM 


r 


I'  lii'Motifiiil 
■sc  piitionta 
•liiir.  Tt  is 
nu'iultranc 
iiiUt'i'ial. 
sul»ii(Mik'  or 
K'lK'tit : 


nations  and 
sjtii'ion  of  a 
ir,  wliicli  lias 


lltlT. 

ins  and  I'oni- 
(|jiiri.'s.  Thi' 
Is  ituniodiati' 
die  some  one 
ri'  atnonnt  of 
ely  are  we  to 
trans  is  jnsti- 
ation  l>y  the 

ever  be  nsed 
•  aeute  symi)- 
wing  pill : 


rrnrLAi:  .v /•;/'// A'/r/.v  ^1 

IJ    Mii--;f  liyilniri,'., 
I'lilv.  (lii;it»li-, 
Kxt.  oiil'cyiiilii'li-'i 
I'ulv   scillii'.  Mil  irr.  i.  — M 
Si.._Ai..ll.'V.:-y  tw.,tlMv,.,orl..Mrl.,mr.. 

Should    this  tail    ...    iu-.vas..    th.    s...vti..n    of    urine, 
u..  .n.all   doses  of   the   iodide  or  aeetate   o     pota^.uun 
:;:;,/:;.   without   digitalis,   o.-  haUun   eo,.ad>a  and   u-on 

^•'t;:;::^tlK.newdiuMiesfn.n.w.ldelMnuehisex,eet.^ 

i.  diuvetin.     Those  who  have  experuuented  with  U   thu 
;•:  and  seenWo  adnnt  its  diuretie  quality  are  n<,t  a,^^^^^^^^ 

ns  to  its  nnxle  of  aetion.  •  i  :., 

Le<>hserversn.aintain,hatitisahourttonn.and      - 

.,:..es  the  Huantity  of  urine  hy  nu-ans  ot  mereased  hlood- 

'^'it- ih^^e  measures  tail  .o  ,r<,duee  a  tree  diuresis,  .unl  the 
.V   M.toms  heccne  urgent.,  we  n>ay  appeal  to  the  slon 
Th  vodernde  inieetion  of  ,.ih,earpin  or  the  not-ajr  .^^^^ 

l^U.;   ame  thue  eausing  the  howels  to  aet  very  tree     . Uh^ 

1  n.   driehm  doses  of  eonipound  .lalap  powder  exe.v 

i:::^';^!'  tl^s  or  resorting't,.  (MutterhueU's  ehderuun 

Td     .^ofone-tweltVhto<,ne-tithvnthofagranua..^ 

,.„.U,ined  with  a  little  blue  .nass,  every    wo  to  io 
;;:„;:r    The  adnunistration   should  he   eont.nued   untd 
ooi. ions  watery  diseharges  are  seeured. 

t  has  heeu  mv  eust.uu,  eaeh  year,  to  mt,-oduee  to  the 
..•al  tin.^elass:while  at  the  .puz  in  n,  othee  nu  t..t 
^^.^r;;-aeut  tuhnhn-  nephritis  whieh  entn-ely  reeoy- 
el^lTgentlennu.  is  now  and  has  been  lor  years, n 

,  ■  .t  health  WlH.n  he  c.nsulted  n.e  he  had  snttered 
'^^^^^.^ri.nr.non.U^.  The  atta.dcl.gan  with 
:;;;;;dlilK,.nen.ver,  pains  in  t..bae.,.^^^ 


vomiting. 


soini    ie>ei,  i>iiii>.'  ■ -  ,        .    . 

'The  dn.psy    was    extreme.      The    phys.eian 


BH 


')-2 


i>isi:.isi:s  III'  Till-:  a//.'.v/;j-.s. 


wli'iiii  lie  hail  pri'vidiisly  (•(disiiltcil  luiil  iiiailc  incisions  in 
his  t\'v\  and  h-ir^,  tii  prfvciit,  as  lie  said,  liic  skin  from 

hiirstiniT- 

He  was  vcryaiii'-inic,  liad  a  vt'rv  weak  imlsr,  with  ^ivat 
dysiUHi'a,  and  was,  in  fact,  coiniilctidy  watcr-loir.ii'cd. 

The  urine  when  hoiK'(l  in  the  tnlii'  showed  two-tiiirds 
of  its  liulk  solid. 

I  coniiueiiced  the  treatment  hy  ahdoTninal  aspiration, 
taking;  away  fourteen  <iuarts  of  Unid,  contininj;  him  to  a 
milk  dii't,  and  i^ivint;  him  a  comhination  of  ai'senic,  iron, 
and  halsam  co|iail»a.,  with  an  occasional  dose  of  compound 
jalap  jiowder  to  secure  wati'ry  discharsres. 

After  aspiration  the  anasarca  (U'creased  to  a  coiisiderahlo 
extent,  hut  at  the  end  of  tw(»  weeks  it  was  almost  us  had 
as  it  had  hei-n  hefore,  while  the  ahdominal  cavity  tilled  to 
such  a  de!.n'ee  that  on  my  second  aspiration  I  removed 
eiu'lit  (piarts  of  Huid. 

After  this  tappins;  [  continued  tlio  ahove  mixture,  as 
also  the  jalap  once  in  two  or  thri'c  days,  irivini;  Idni  every 
alternate  day  a  hot-air  hath,  which  relieved  him  each  time 
of  a  irreat  ((uantity  of  water. 

Hice  was  added  to  his  milk  diet,  with  good  mutton- 
hroth  once  a  day. 

There  was  no  more  ascites.  T!ie  anasarca  soon  dis- 
appeared, and  in  two  or  three  months  no  trace  of  alhumen 
was  found  in  the  urine.  As  I  have  said,  this  was  my  first 
had  case  of  acute  tubulitis  which  recovered. 

Pneumonia  is  a  c<tmplication  which  we  are  frecpiently 
called  upon  to  treat. 

The  i.neumonia  of  Uright's  is  of  a  peculiar  character. 
It  is  seldom  that  we  find  a  characteristic  lohar  pneumonia 
ushered  in  hy  a  severe  chill  or  hitfli  fever  and  involving  a 
whole  U)he  of  the  lung. 

The  patient  is  likely  to  have  slight  chills  or  rigors,  fol- 


TCiui.Mi  .\i:riii{iTis. 


9^ 


u'lsKtns  111 
skill   tVoiii 

^vitli  ifiviit 

t\v()-tliir(ls 

is|iii'ati(>ii, 

liiiii  to  a 

I'liic,  iron, 

i'Olll|ioUll(l 

urtiderablo 
lost  as  bad 
ty  filli'd  to 
[  rciMoved 

iiixtun',  as 
liim  fvcry 
oacli  time 

id  mutton- 

1  soon  dis- 
)fall»nnion 
as  my  first 

frequently 

character, 
|>neumonia 
nvolving  a 

rigors,  tbl- 


lovvcl  l.v  a  tcmpcratuiv  ..f  hy^  or  10:',°  F.,  with  more  ol 
a  l.n.ii.  iio-iMicumoiiia  tlian  a  lobar  pncumoina. 

The  lun-^  he.M.mes  involved  from  .liU'erent  centres. 
lU.voiul  the  inflamed  ,.ortions  we  tind  u  .lein;.,  with  its 
s„herci.itati..ns.  The  dys,.nu.a  ..fteii  hecomes  nruvnt,  as 
not  <.i.lv  does  the  fortion  ..f  the  lung  not  inilamed  heeome 
ced.ma'tons,  hut  the  other  lung  as  well.  In  examnnng 
thesr  h.n.^s  |.ost  mortem  we  tind  that  the  intlammatio.i  is 
developed  from  difVerent  centres,  as  in  lol.iilar  l.nen.nonia. 

The  Inn.'  is  not  s.didlv  hepati/cl,  as  the  exudation  is  not 
vorv  lihrinons.  In  cutting  into  it  the  whole  Mir»a.'e_  is 
hatiied  in  hlood,  and  we  Hnd  the  air-cells  tilK'd  with 
hlood,  serum,  mucus,  and  leu.'o.ytes;  never  the  dry,  hrm, 
fibrinous  exudation  of  a  pneumonitis. 

Only  a  few  weeks  ago  my  last  patient  who  died  of  pneu- 
mmiia  while  suffering  from  tubulitis  had  a  succession  of 
chilly  sensations  from  da.N  to  day  as  the  pneumoma  kept 
invailint;  the  lung.  It  commenced  at  the  left  base,  and 
proirressod  upward  until  almost  the  entire  lung  became  in- 
volved. Ab..ut  the  fourth  day  of  the  pneum..nia  (cdeina 
betran  in  the  ritjht  lung,  with  some  hypenemia.  Although 
I  iH.pealed  to  the  skin  and  bowels  and  tlu'  urine  was  not 
verv  scanty,  I  failed  to  arrest  the  (edema  of  the  lungs. 
The  dyspiioni   became   extreme,  and  death  occurred  m 

eonsecpience. 

As  soon  as  the  patient  leav(«s  the  bed,  in  acute  as  well 
as  in  chronic  eases,  great  care  should  be  taken  with  the 
ch.thintr.  lleavv,  warm  underwear  should  be  worn  coii- 
tinuouslv,  and  a"n  over<-oat  should  always  be  at  hand  to 
insure  the  patient  against  the  effects  of  sudden  changes 
in  temperature.  It  n.ay  be  safely  said  that  no  <lisease  is 
more  benefited  l)y  a  warm,  eipiable  climate  than  tubular 

neithritis. 

(?/om(77//o-.V<7>/*/v7;...-Klebs  was  the  first  to  call  atten- 


ttman 


!>4 


i>isi:.isj:s  OF  THE  KinsKYs 


tioii  to  this  tonii  of  in'pliritis,  (iccurriiiic  I'sin'cially  in  ^H'llr- 
h't  tV'Vcr.  It  isoi"  iiKii'c  iiitiTcst  to  tlic  jtiitholoti'ist  tliaii  to 
tli(;  ('liiiician,  us  it  \voiiI<l  la-  iiiipossihlL'  to  (li'tiiiiiiiic  in 
iiiiv  ciisi^  ot'  iu'|iliritis  wlu'tlicr  the  disuiiso  was  roiitiiifd  to 
the  ,i;-l(*iiu'nili.  Wo  liavi,'  jdri'ady  otH'rfd  tho  sUiLr,ir«'sti()ii 
tiiat  ill  so-calli'd  jih_vsioloi;i(  al  allduninuriu  the  distuiliiiiicc 
is  coiitiiit'd  to  the  ":loiiu'ruli. 


ci[APTi:i{  xrrr 


■  I 


i! 


INTRRTrni'I-AR  NKl'llHITlS  —  INTKKSTITIAIi  NMOlMIUITIS  — 
(illANl'l-AR  KIDNKV — (ioiTV  KIDN'KY — CONTKACTKI)  KIIJ- 
NEY — CIKUIIOTK!    KIDNIOY. 

Wk  sliall  uso  tile  term  iutertiilmlar  nephritis  to  desi;;- 
tiate  tlmt  form  of  nepliritis  in  which  tlie  priiiiarv  iiitiam- 
mation  eoinmeiiees  in  the  iutt'rtiihnlar  or  tihroiis  tissue, 

K'rioliOtiY. — The  eticdotry  of  iiitertuljidar  nephritis  is 
limited.  Its  eaiiacs  are  less  numerous  than  those  of  tubu- 
lar nephritis. 

(■/iiiKitc. — Like  tuhular  nephritis,  this  eondition  is  more 
common  in  the  temperate  than  in  the  torrid  or  frii^id 
zones.  While  elimate  can  hardly  he  said  to  be  an  etio- 
lo,u:ieal  faetor  in  this  form  of  Hrityht's  disease  as  it  is  in 
tubular  nephritis,  cold,  damp  seasons  are  eertainly  re- 
Kponsible  for  exat-erbations  of  the  aft'ection. 

A(/r. — As  a  rule,  intertuhular  or  interstitial  nephritis 
may  be  said  to  be  almost  exclusively  confined  to  those 
who  Inive  passed  middle  life.  We  have  already  seen  that 
tubulitis  is  more  fre(pient  in  childhood  and  early  life. 
Where  occasionally  we  find  intertuhular  nephritis  in 
childhood  or  early  adult  life  it  is  ^'cnerally  in  a  case  of 
hereiUtary  gout   or   strong  gouty  diathesis.     Of  course 


u_ 


isTEiiTi  r.fi.Mi  si:rnniri><. 


05 


]_v  ill  rH'iir- 

ist  tlllUl  tn 

I'l'iiiiiic  ill 
oiitiiii'd  to 
iiiiru't'f^tioii 
iMturliiiiicc 


iMIltlTIS  — 
■Ti;i)      KID- 

s  to  (k'siu- 
irv  iiiriaiii- 
irt  tissue, 
.'idiritis    irt 
SI'  of  tiilm- 

iiii  is  iiiort' 
I  or  friijid 
bo  an  t'tio- 
as  it  is  in 
rtuinlv   ro- 

iu'i)liritis 
il  to  tliose 
y  soon  tliat 
early  life, 
pliritis  in 
1  a  ease  of 
Of  oonrso 


l,a.l-i.oisonin-ora..,tono,.linti^  '"iKl't   l.nn-  al.out  tl.is 
ron.litio.iinllu'ooiiii.anitivoly  vounir. 

.sv,  -\lalos  aiv  niurh  nio.v  suLjo.-t  to  tl.is  .lisoasr  than 
fomalos:  -out  iH.i.m-  nuiol,  nioro  fro.,urnt  in  n.alos  than 
i,  foniak-s,  an.l  mon,  hy  ivason  of  ti.oir  hahi.s  an.l u- 

,.atioi.s,  boin^  n.oiv  oxposo.l  to  untayorabh.  •">l'"-;';-; 

ItisvorvsoMom  tlio  ivsult  of  in.p.ry  or  amtr  tubu  .  i 
,H.,,britis,  ami  it  is  baroly  possible  that  it  is  o.v,     .mally 

the  result  of  liyi>eneiiiia.  _ 

Aloohol  is  sui.l.oso.1  to  l.ro,luee  this  eon.lit.on  :  wlion 
it  does,  it  l.robablv  follows  aleoh..lie  hyi-eneiiiia.  Nune 
of  the  eases  are  attributed  t..  obrouie  malaria;  a  l.w  are 

erodited  to  sypliilis.  

It  is  a  .luestion  whether  the  exoossivo  use  ot  vor.N  stn...,^ 
tea  may  not  be  a  faetor  in  produeing  a  hyperi-lasia  ot 
iibrous  tissue  in  the  kidney.  i         •     i      i 

It  is  imt  an  infre.iuent  oeeurrenee  tor  workers  in  lea<l- 
nnnes,  painters,  .u.  tli..se  who  are  eonstantyinhan,.  or 

abserbin,^  lead,  to  sutfer  with  this  tonn  ot   l.r.^d.t  .  d.>. 

ease  (saturnine  poisoninji)-  .     ,        ,         •     •     i 

But  the  oxperionee  of  all  observers  is  that  the  pnu.ipa 
cause  of  intertubular  nephritis,  -ranular  kidney,  is  r". 
We    mav  even    tind    this    eonditb.n    in    people   ot   ^-outy 
.Uathesi.;  wlm  have  never  exhibited  any  of  the  ordinary 

svmptoms  of  srout. 

■  PVTIIOLOU v.- Unless  the  patient  dies  tron.  some  inter- 
current disease,  we  do  not  have  an  opportunity  ot  oxam- 
iniuii  the  kklneys  in  the  earlier  sta.u^'s  ot  intortubular 
nooi.ritis.  When  sueh  an  opp<.rtunity  <loes  otler,  we  tiiul 
the.n  oulanred  from  the  proliferation  and  inerease  ot 
iibrous  tissue,  just  as  the  liver  is  in  the  early  sta^e  ot  eir- 
rhosis  of  that  oi-an.  W."  .iTenerally  see  the  kidnoN .  n  hen 
thev  are  small  in  size,  irregularly  eonti.a-te.l  ami  nodular 
by  "reason  of  the  eontraetion  of  the    new  tibrous  tissue 


«Maa 


w 


i)ish:.\si:s  or  riii:  hiiKShns 


!i 


(st'c  K'lL'.  !-)■  A'  timi's  tlirv  ii'>  IniiLTtT  |ir.'s«r\  f  till'  >li;ii'f 
..fa  kitliH.v.ntt.ii  .•xliil.itiiiir  a  liirir.'  iiiiiiiImt  of  .vsts  tVoin 
llir  size    uV  a  lull    |M    tliat    of  a   walnut.      'IMir  rai.^ulc  i> 


..losrlva.lhrrrnt.aii.l  in  ouri.iVorts  t<.  n-inovoit  the  .irranu- 
lar  tissue"  (.ftlic  ki.liu-y  is  uth'ii  torn.  Tliis  tot-nis  a  n)in- 
pU'to  contrast  to  tlu-  sniootli  sliinin.ir  surface  aii.l  casil.y- 
strii-i-i..!  rapsulr  of  tul.ular  lu^phritis.  A  section  of  this 
ki.lnev  un.ler  tlie  microscope  shows  ,irreat  increase  of 
fihrou"s  tis>ue.  with  con)i.ressi(.u  and  atrophy  or  (U'struc- 
tion  of  many  of  the  Mal^i.-rhian  corpuscles  as  well  as 
tuhules.  (Set'  FiLr.  l;5.)  i^iiiall  cysts  are  often  found  scat- 
tered throu./li  the  cortical  i.ortion  of  the  kidney,  and  are 
the  result  of  dilatation  of  the  Malpi.irhian  tufts  in  eonso- 
,,u..uce  of  ol.structiou  of  its  tuhules  hy  new  lihrous  tissue. 


•   ill.'  -]\H\>r 

cysts  tVoiii 
lUiisiiU'  is 


ri'iiiiivfil  friim  a 
r  ixIriMiiily  cull, 
ivcll  till'  >.'iiiimliir 
null  mill  iirciiily 
iiiry  iiiilliipUit!i('iil 
f  result  111'  ariiti' 
I'l'jvi'ii  yt'iir-  I'M. 
Icr  lu'iiltli  iliirliii! 
•  urine.  Imt  viiry- 
il  tiniilly  ilieil  III 
}  iii'curred  in  the 


it  tlio  irraim- 

oriiis  u  c'oiii- 

1111(1  i'iisily- 

.•tioii  nt'  tliis 

ilUTl'ilSl'     dt' 

,•  or  (Icstruf- 
s  as  Wfll  as 
I)  touiiil  srat- 
\n'\,  and  art' 
fts  in  I'oiiso- 
l)rous  tissue. 


lyTHirn mi. mi  .\i:i'IIIiitis 


'.•7 


noui„;.irs  rni.Mil..  aiul  the  ualls  -f  tlir  1.1u.h1.v..ss..1s  a.v 
tl.i.k.nr.l.  aii.l  many  of  tin'  ti.l.uK-s  aiv  .l.i.inl.'.l  nl  tlinr 
i'|iillu  liiini. 


Km.  VI 


Stiruun.  ,.h..t,,|..nM..ie,,  .,y  .1.  r.  Speiieer  )--.,  .,  vertleal  .n„  ,„„K.t....u,al  senl.m 


Moiiiiteil  l>y  J.  n. 
Iiiial  seclloii 
rimvU's  mill 


Stulliiril  mill  ,.li..tui;m|.lie.l  i.y  .i.  v  ■  .-l-e ,     ■  .  -■-■■•."  .        ,.„r,,„.,.u.. 

.,,aii  i.rtery  ^llo^^,„«  vi.mi  reniil  elimiKOs;  ,■,  el, inters  of  ^'"'"  «       l';"'"'  "■ 
,,n.llfer,aeil  liitirtuM.lur  lil.nms  llNS,ic.-<'omi,lete  abs^'nee  of  tulmlts 

Symi>t..ms.— As  svv  have  ulroady  socn  from  tlio  etiolo.iry, 
tlu.  iiutient  is  pn.l.al.ly  a  male,  past  mi<l.llr  lilV,  ami  ni 
n.unv  cases  the  subject  of  -out.  Fii  tin'  early  stajres  ot 
tlu'  disease  the  symptoms,  as  a  rule,  are  m.t  sutheieiitly 
marked  to  attract  the  atti'iition  of  either  patinit  ..r  phys- 
ieian.  The  disease  is  very  slow  and  inddi-us.  In  some 
eases,  however,  there  is  sufHeieiit  hypenemia  to  produeo 

9 


i 


08 


i>isi:.\si:s  itr  riii:  kidmis. 


iifliiiii;  pain  iil"Mit  ili.-  liack  ami  l«iiiM.  with  f'n'i|iiciit  mic- 
tiirilinii.  wliilf  iM<  ;i»i..iiiill.v  u>-  iin'.t  wifli  In  iiinrrluiirf  in 
tlu'  «'aflit'>l  slairi'-'  <'t'  ,ir<'ii«v  kiilm  y. 

Art  tlif  ilirtt-a:'!'  ailvantTi,  flic  f_viii|itniiis  litrmnr  -iitli- 
ficiitlv  (Iffiiit.l  to  iiltrii.t  tlir  altciitinii  ,>\'  ilu'  patiiiil. 
\Vr  r-hall  us  lally  »iii<l  rii  inm-iisfil  i|ii:uirn,v  nt'  iiriiir.  of 
liirlit  >|«f<ilit  ,iria\il\  ami  rolor.  nuituiiiiiiii'  a  sniiill  t|iiaii- 
r,;v  ■•!'  !il!;;imtii  (\v«'  art'  luTt'  ri'liTrinur  |iiirti«'iilaily  to 
iruiilv  kiiliicv).  Willi  v.'ry  U\\  lulM-.ii>ts.  wliicli  iiillri'  iirc 
n|  til.  Iiviilinc  varii'tv.  Analysis  will  sIk.w  ii  .l.tiritn.y 
in  ilic  iiiiiuiiiil  III'  iirt;i  cxcn'tftl. 

'I'l'i.-  fniiilitiiiii  (.1'  tliiiiii's  may  ir"  "n  fi.r  mmitlis  or  years, 
till'  (list'iisf  lifiniT  very  cliroirK'.  ami  rlir  palinil  may  ••on- 
siili  lli>'  |iliv>i.''iiii  tor  coiiiiirKMiioiis  or  iiitfrniiTii't  ilis- 
vast's  lis  tlu'V  arise.  X'oiiiitiiiir  may  Utoiiic  ti'oiil>K'-omc, 
or  scvf.'i'  lii-adaclics  may  (lfVflo|i ;  not  iiitrf.|m'ntl\  llii- 
iiMliciil  (■oii>ults  till'  pliysiriiin  on  account  of  lo>s  of  >iL'lit, 
(Hill  Irani-  for  tin'  fii>l  time  that  he  has  chronic  I'.riv'ht'rt 
ilisi'usi'.  'rill'  ilisi'.isf  o|' the  i-yc  most  common  is  retinitis; 
anil  \\<  characteristics  are  .>o  marhcil  that  oculists  iVe- 
ijuently  make  a  <lia,trm>is  of  chronic  i'.right's  tlisease  tVoi.M 
the  aiU'caranee  <>f  the  retina. 

Another  coni|.lieation  whicli  these  i>atieiits  rarely  eseaiu; 
i>  hviicrtrojihy  of  tie/  left  heart.  Various  theories  have 
hceii  ailvanced  to  eN|.laiii  this  eomlitioii.  Mritrht.  hiiiisclt', 
atlriliute.l  the  cardiac  hy|iertro|.liy  to  chemical  ehanu'es  in 

the    1.1 1,  or.  a<    he   e\|iresses   it.  an   impure  state  of  the 

hloo.l  which  stimulaii'il  the  heart  to  excessive  actMty.  or 
hv  reason  of  its  altered  (juality  re.|uired  more  hn'ce  to 
jiroiiel  it  throuirh  the  ea|iillaries. 

Trauiu'  was  of  oiiinioii  that  the  increased  ai-tioii  of  the 
lieart  was  due  entirely  to  an  ohlitcration  or  contraction 
of  a  lari^e  niimher  of  renal  arterioles.  This  theory,  how- 
ever, has  heen  shown  to  he  untonahlo. 


t  - 


mm 


iSTKirri  III  i.M!   SEi'iiiiins. 


00 


lent   tlllc- 

I'l'liiiiri'  ill 

lllr    -lltH- 

'  |i:iti('iit. 
iirliii',  of 
mil  ijiiaii- 
iil:irl_\  ti' 
lallt'i'  ill')' 
ictiriiiify 

iiiav  coii- 
rni't  ilis- 
iMi'-iiiiif, 
ciillv  lllf 
^  ..r  >ii:-lit, 
■  Till -I  It's 
rrtiiiitis; 
ulists  tVf- 
«'iisi'  iVoi.'i 

vly  cscaiK! 
irics  lijivi- 
I,  iiiiiiscll', 
•liaiiircs  in 

ate  ct'  till' 

(t'vity,  or 
I'  t'on-i'  to 

iuii  of  till' 
oiitractioii 
I'orv.  liow- 


(!,.or,u'*-  .lnliii>oii  al  lir>l  a.lvaii.r.i  llir  i<l.a  thai  tlf 
|,y|.rrlro|.l.v  wa^  owiiiiT  »"  >i  lii.^'l'  l'l"o.|-|.n"iiiv  -aiisr.l 
|,"v  u  tl.irk.'nii.i;  of  ll...  imi.Miilar  walls  of  tl.r  ivnal  art-- 

riolrs.  l.iil  s.il.MM,ii.ntly  f. 1  ilial  lli»' lliirk»'iiiii.if  was  not 

•  •onliiii'il  to  tlif  arltriolrs  ..f  tlir  kidney. 

Sir  William  (lull  iin.l  Siitlon  .•oiifirm.Ml  l! i-inioii  of 

.IuIhhom  in  ivu'iinl  to  tl..'  tlli-'kruill-  of  ihr  walls  of  tlu- 
m-t.Tiol.'s.  .lolin>..n  niainlaii.r.l  that  tl.r  mus.nlar  .•,..! 
uf  tli.' Nvss.-ls  was  tlii.kolKMl.  wl.ilc  (lull  au.l  Sutton  sl.uwr.l 

that  tin-  niMs.nlar  <'oat  in  ivally  atrophi.d,  it  h.inir  tin- 
•„,„..,•  an.l  *xt»rnal  roats  whhh  aiv  thi.-kcin.l.  an<l  that 
tl„.  nal  patholouMnil  ••on.lilion  is  a  irmnal  ait.rio-.apil- 
laiv  fii.rosis.  with  a  U'ss.'nin,ir  of  tin-  Ininina  of  the  Vfssi-is, 
thu^  foiviniT  a  ,M.nii...nsalory  i'MTtion  npon  thr  heart. 

A  lar-T'-  niiiiil"'f  "f  patimts  siilhTiii- iVoni  int.Ttnhnlar 
,„,,,l,ntis  soon.r  or  latrr  .h^vlop  an  athrron.atons  .•on.li- 
tioM  of  thr  art. Ti.-.  an.l  this.  .■..n.hin.Ml  with  th.'  .'Xtra 
,;„,.,.  fn.n.  th.-  hyiMTtn-phi.-l  heart,  offn  results  in  heni- 
urrha-'.-s  from  various  art.-ri.'s.  ami  parti. Milarly  m  eere- 
l.ral  ap"'l'l''^v,  many  .lyin-  in  this  way.  N..  <'  "iht  th.' 
l,,,,„„rrhairi-s  fr..m  th.-  ki.lii.'y  in  th.'  later  sta.tres  ar.'  also 
il,,.  r.-ult  of  this  .l..nhl.-  .•anse,— viz.Jiyperlrophie.l  heart 
ami  alher.imatons  arteri.'s. 

Anoth.'r  fre.pu'iil  synipt..iu,  th.'  r.'snit  ..f  th.'  ah..ye 
eauses,  ami  rarelv  .x'.'urrin.i;  in  tuhular  n.-phritis.  is  epis- 
taxis.  I  have  lia.l  s.'vral  pati.'iits  with  int.'i'tnl.ular 
nephritis  who  have  heeii  th.'  sul-j.-.ts  ..f  atta.'ks  ..f  ha-ma- 
tem.'sis  imlepemlent  ,.f  .'irrlM.sis  of  the  liver  or  uh'erati.m 

of  the  st.iiuaeh. 

It  is  in  this  f..riu  ..f  Hriirht's  disease  that  w  most 
fiv.pu.ntlv  tin. I  ura'mie  p..is..nin,tr,  manif.'.-t.'.l  .ith.'r  l.y 
eonvulsi.uis  .)r  hv  .'..ma  :  while,  .*.i  the  ..ther  haml.  we  s.'l- 
,hmi  meet  with  what  is  nea.:,-  always  present  in  tuhnlar 
nephritis,-nainelv,  dropsy.    Thus,  a       .u  will  ..hs.'rve.  the 


i 


J 


100 


nisF.Asi:s  or  riir.  i<insi:yt<. 


i    ! 


..liniral  histnrv  i^  n.arki-.ll.v  .litKiTnt  in  llu'so  t\v..  foriiH 
„f  nrplirilis,  as  aiv  als..  tlir  i-tiol.»Lrv  and  i.atl.nh.-r.v.  (M 
rours.-  in  tlu-  ton-  casi-s  ..f  intcrtMl.iilar  nrpiintis  rrsnlt- 
in.^'p.iM  tnl.nlar  nc].l.nlis  tlic  syniftoins  aiv  lliosc  ..t  a 
rhn.nir  ..r  i.n.l.m-r.l  .•..n-lition  of  tiiLiilar  luflintis,  ratlu-r 
than  tliosi"  pivsi-ntcd  durinLT  \\xv  insidious  pn.irivss  of  an 
iiitiTtuliidar  tupliritis. 

Int.Ttul.Mlar  nephritis  tho  .vsult  of  ha-I-poisonni-^  is 
„ut  so  rhronir  nor  so  lil<rly  to  In-  a.ron.i-anir.l  l.y  .•ard.a.- 
hyiKTln.i.liy  or  ivtinitis :  hut  synii.toms  of  .•hronic  Icad- 
noisonin;;-  will  1k'  pn'scnt.  _     _ 

IntiTtnlmlar  nrphritis  tl.c  result  of  ••lironi.-  malaria  is 
usuallv  iuvoinpanird  l.y  n.oiv  or  loss  fnlar-nnrnt  ot  tlu. 
snkH'n'  and  livrr  and  .K'ran.i^^-nu'nt  of  the  latter  viscus. 

]»,i„,iN..sis.— The    proiriK'sis    of  inti'rtul.ular    luplintis 
dcurnds  laru^'lv  uvon  tlu'  sta.iro  of  the  disease  in  wl.ieh  w.- 
ti„d  the  patient,      fn   the  earlier  sta-es  the   pro-nosis  is 
favoral.le  so  far  as  anv  iinniediate  danu'er  is  eoneerned  : 
hut  the  kidiu-v  never  re-ains  its  i.hysi-.lo.irieal  condition, 
a„d  the  disease  steadily  pro-resses.     Later,  we  must  he 
verv  iruarded  in  our  pro.irnosis,  as  an  athenunatous  artery 
mav  "ive  wav  at  anv  time,  produ.injr  eerehral  apoplexy, 
or"hrm..rrhairelV..m   the  lun-s  or  the  st.unaeh:  or  the 
patient's  life  mav  he  out  oH"  summarily  hy  ura-nue  eon- 
vulsions  or  eoma,  hv  a  severe  attack  of  .ir-ut,  or  hy  pneu- 
„,„„•,,,  or  capillarv  hroiu-hitis,  to  whi.-h  sul.je.'ts  ot   this 
disease  are  very  liahle.     Pericarditis  or  endocarditis  may 

terminaU'  the  case. 

TuKM-MKNT.  — NVe  have  no  specific  lor  mtertuLuiar 
„,,,,hntis:  no  wav  of  rest.u-ini;  the  kidney  to  its  normal 
condition.  We  can  .K>  much,  however,  hoth  to  prohmi; 
the  patient's  life  and  to  make  it  more  comfortable  hy  strict 
attention  to  diet  and  hy,i;ienic  surroundinjxs. 

The  diet   shouhl  he  nourishing,  hut   not  excessive  or 


M 


J 


^mm 


isTF.iiTi  lULMi  yF.i'imrris. 


101 


(t  ioriiH 
xy.    <  >r 

*  rt'sult- 
ost'  of  a 
s,  ratluT 
SH  (if  an 

iiniii!^  if< 
,■  canliac 
lie  Icad- 

lalaria  is 
i\t  of  tlio 
iscus. 
iu'|>liritis 
,vliicli  \vf 
i!;ii()sis  IS 
nconu'il : 
oiiditioii, 

must  l>i' 
»ns  artcrv 
[ijioiilrxy, 
1 ;  or  tlu' 
■mic  c'oii- 

by  piR'U- 
ts   of  t]liH 

'(litis  may 

tortui  Hilar 
ts  normal 
to  proloniT 
k'  by  strict 

:cessive  or 


stinuilatinL',  and  shonld  Ik-  lar.ijcly  non-nitro,-r«'noiis,  con- 
sisting of' rice,  milk,  vcirctablcs,  tish,  and   fowl,  with  a 
limits  amount  of  otlicr  meat.     Clothin.i;  slionld  receive 
special    attention.      Tiie     patient    should    he    completely 
clothed  in  \vo,.l.      As  to  climate,  there  are   few  diseases, 
n()t   even   exceptimr  those   of  the  Inni^^s,  which  arc  more 
lu-nefited  hv  a  mild,  cMiwdde  climate  than  is  intertnhnlur 
nci-hritis.    "in  other  words,  tiie  function  of  the  skm  must 
Ik.  carcfullv  watched,  the  Hannel   clothintr  assisted  by  the 
warm  climate  encoura-riiK-r  aii  e(iuable  and  active  c..ndi- 
tiou  of  the  skin.     As  for  medication,  it  is  larijely  a  matter 
of  treatiiiir  sympt-.tiis;    and   the   symptoms  which   anso 
during  an"  intertubular  nephritis  are  in  many  cases  the 
results  of  deran.irement  of  oru'iiiis  other  than  the  kidney.s 
themselves.     The  patient,  perhaps,  has  vomiting,  which 
must  l)e  c(mtrolled  hy  appropriate  treatment;  or  he  may 
iomplain  of  headache,  or  there  may  l>e  epistaxis,  which 
demands  our  attention. 

Frecpi-ntly  we  are  called  upon  to  treat  an  attack  of  ir<>ut 
or  uruMiic  symptoms;  while  few  of  these  patients  j,'et  on 
without  more  or  less  chronic  bronchitis.     Tiie  treatment 
of  any  of  these  complications,  even  to  that  of  ajioplexy, 
must  "he Conducted  lar-jely  on  .ireneral  medical  principles. 
The   kidneys  themselves,  however,  often  exhil)it  symp- 
t(.ms  that  re(piire  attention.     They  may  become  byi.er- 
iiMiiic  or  the  subject  of  hemorrhajje,  while  occasionally 
thev  suffer  from  "attacks  of  tubulitis;  that  is,  durini:  the 
course  of  this  disease  we  often   find  tlie  urine  .!,n-owin«,r 
less  in  (pmntity,  of  hijrher  specific  gravity,  and  containing 
a  larger  amount  of  albumen,  (I'denia  of  the  extremities 
lieing  simultaneously  present.     We  immediately  enforce 
absolute  rest,  and  resort  to  the  remedies  that  have  already 
been  referred  to  in  describing  the  treatment  of  subacute 

or  chronic  tubular  nephritis. 

9« 


r 


lOli 


nisi:AsKs  or  riii:  i<ii>M:is. 


fl 

"   —         « 

1- 

Six.    7 

st 

o-=          i 

^"     "                   — 

a. 

^ 

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a 

.  rT 

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4-* 

H 
1 

d  t  =  ? 

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.£ 

X 

illi-^l 

H 

tr  '-A  S-  si 

J**, 

' 

^ 

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/, 

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'-  "3  ■£! 

X 

- 

'  ^ 

B 
u 


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C    £1 


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4   r    ClSs'-S 

;£  u.  s-  S    /,  i  ;^ 


f".!'  I  [y  J  I 


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■7  e  . 
.  i  if  ^ 


.^ ;_  _:  J  J  J     "X,     >5 


a 


c 


I  J  1  rJ 

~     i    t-    -ic    r        i    -    C 


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>•  Z'Zi  -  ~  -  'i. 

7.  =:S3  ri  i 


e-    ,5     z 

a      _ 


—       1^      « 


•/, 


33 


u 


~3 


SF.l'IIUITlS 


103 


(MlAl'TKU    ^"V. 

NKl'lUUTlS-l.lKKrSK    N  KIMIUITIS— NKIMIIUTIS    VEUA-PAHICN- 
OIIVMATorS  NKl'llHITlrt. 

Ik  tho  un.inaliti.Ml  Wvm  lU'i.l.ritis  is  un.U'isto<..l  an 
juMiU'  intlan.iuation  of  tlu-  ki.ln.v  wl.i.'l.  iMv..lvi.s  all  tl.o 
ti.<iu's,  and  .•orn'siM.ii.ls  t..  that  om.liti..n  ot  the  lnnj,'s 
whu-h  wt.  .losiirnati-  as  imrnnionitis  or  lu^pati/.t-l  Inn,-. 

E'rioLo.iY.— TluTc"  is  n..  rausc  that  pn..lu.rs  a  tiihuliti. 
Nvhic-h  niavn..t  vro.lmv  a  .•..n.pK'to  nophntis.  For  in- 
stanns  a  nq.hritis  iuvonipanvin-  scarlet  fever  or  .lii.h- 
theria  mav  he  tuhular,  ueute,  or  snhaeute, or  a  nophnt.s 
nnmer  involvin-  the  entire  strueture  of  the  ki.lnev.  the 
(lilfereuee  in  the  intlarnnation  in  tlu-se  .-asi'S  he.n.ir  one  ot 
dco-ree;  so  it  nuiv  also  l»e  when  resulting  from  nevere 
eo'hl  su.hlen  suppression  of  the  perspiration,  pre,<rnaney, 
sovere  injurv,  or  anv  of  the  hloo,l-poison«  that  produce 
tuhular  nephritis.  We  shall  find  that  the  .litferenee  is 
patholoirieal  and  elinieal  rather  than  etioloj-u-al.       _ 

I'MHOLO.iY.-It  nuivnot  he  possihle  to  distinguish  hy 
thi>  naked  eve  the  lar^^e  red  kidney  of  tuhular  nephnt.s 
from  the  lar-e  re.l  kidney  of  a  recent  case  ..t  dithise 
nei.hritis,  as  in  the  earlv  sta-c  of  the  latter  the  kidney  m 
its  -ross  appearance  will  he  practically  the  same  as  in  a 

tuhulitis. 

Outtincr  into  these  larfje  kidneys,  we  shall  hnd  th*'m 
hvpenemie  in  hoth  eases,  with  an  oozin.ff  of  hh.o.l  on  the 
ciit  surfaces,  and  the  Malpi-hian  hodies  distendc.l.  l.ater 
in  the  disease  the  crtex  is  pale,  and  often  .edematous, 
eontrastin-  stroni^ly  with,  the  <lark  congested  pyramids. 


k:^ 


1 


104 


nisi:Asi:s  or  tiik  h-inxins. 


5 


A  iui.r..M..i.i<-al  .^cfticn  ..1'  thr  ki-liirv  of  lu'i-liritis  will 

sliow  a  iiii>ri'  f()!ui>lfli'  filiri- 
Fid.  14.  iioiis  fNiiiliitioii  into  till' iiitiT- 

gMir^'-^i  Vv^'j  -^ ,         tiiliiilar  sjiaffs  than  ocriirs  in 

^^^-'d' KfyiL':0/ -jI    tiii.iiiitis. 

Till'  I'liitlu'l"':;!  (clls  air  in  a 

conilition  of  iri-aiinlar  d*  u'*'!!- 

'f^'KSf^i^^M:^'''^^^^-       .ration,  and  tin-  intiTtuWiilar 

JA'<^:VJ^'^f'l'''X<-'.'i.'^iy'^      li^siii'  is  swtilli'ii,  (r(U'iiialt)US, 

anil  iiitiltniti'il  witli  ih'W  rrlls. 
Till'    I'fUs    I'DVi'iinir    till'    tnt't 


Wi^rafl^M^i^'^r      anil  liiiin-  U.-wniairs  rapsnlo 


"Ji'-.v 


coTi;]!!'-  --stlK'.tjlonu'niliis.  lii- 
i'ai.tiitns  are  niurt'  likely  to 
Ih-  unil  in  diirusr  than  in 
tiiliui,,!  lU'pliritis.  ''atholo.iii- 
cally  it  coriH'Siionils  to  tliu 
lu'l.atizi'il  Uiiiir  of  iHU'iinio- 
iiitis,  whili'  in  tlu-  tnlmlar  va- 


I'i^.  II  shows  ni'iitt'  iu'liliriUs  |<llf- 
fuse.  viTii].  .«iiim'  cif  till'  lilla's  are 
nUfil    Willi  oxmliUicin  iiml  slmw  tlu' 

i.plllirliiiin  sWdlU'ii.  iiM.l  nil  iricL-uliir  .    .         i  i 

ooniimsMi.ii  fniin  tin-  swelling  of  "ii'i       viotV    of    IH'llhritis    till'    I'XUUa- 
ex«.lHll.min.o,lu.inU.r,„.,ular,i.Ma..       ^,^^-^     ,-„„„l,,tOS     n.oR'     I'loSC'ly 

that  of  a  hroni'ho-imi'iinionia.  In  otluT  words,  in  tnlmlar 
,H.,,hritis  the  inti'rtnl.nlar  spacos  aro  not  ,<o  tl.oroiiirlily  dis- 
ti'iiiU'd  with  exudation  from  the  hlood-vrssi'ls  nor  is  the 
fihrons  tissiu'  so  swolU'ii,  as  tlu'y  are  in  nephritis  proper. 
The  epithelinni  of  the  tubules  suffers  alike  in  hoth  eases. 
It  is  i'videiit  from  this  patholoirieal  condition  that  the 
suppression  of  urine  would  be  much  more  eomplete  m 
nephritis  i.roper  than  in  tubular  nephritis,  beeause  ot  the 
,,„npression  of  the  blood-vessels  by  the  exudation;  and 
for  the  same  reason  this  form  of  nephritis  may,  like  pneu- 
monitis, end  in  abscess. 


.-^-.WBJW»■-»'-««•''^^  -..^-i*^WM«pW»»«(6i««n'»«»»M<P«^'» 


jM JtlW'^Wg^M'aW"^  ■ 


litis  will 
■\v  tiliri- 

lic  illtlT- 

xTiirs  in 

iii'r  in  !l 
r  (Icii't'n- 
•rtultnlar 
I'Mialous, 

U'W  Cl'lls. 

till'  tult 
s  capsulo 
inffcasi'tl 
)nii'linn.'rt 
iilus.  In- 
likrly  to 

than  in 
'atlioloiri- 
s    to    till' 

imi'iinio- 
ilinlar  va- 
11'  I'xuda- 
•0    I'losi'ly 
m  tnhnlar 
nii'lily  dis- 
nor  is  the 
is  |)roiii'i'. 
>otli  casi's, 
I  that  the 
iiniili'tt'  in 
usi'  of  ihi' 
ition  ;  and 
like  pni'U- 


.v/;/'///.7/7.s'. 


lo:. 


Symptoms. —  I  iiis   i 
ui'iiti'  intlaniniation  of  th.'  kidn.'vs. 

II    SI 


i.ltuu-.'lhrf     the     Si'ViTl'st    fonn    of 
It  is  nslu'itd   ill  hy 

,  ,,vi.riT  .•hill   and   hi-ii.T   t;.v..r  than   is   thr   .arlv  >ta-.' 
,,.,,,,,,,,,,  H.,,hntis.  and  is  ar..m.i..ni.'d  hy  si.vvivlM.ad- 

,,,!„..  nrarlv  always  hy  voinilin,!.-,  Mipi-iTssion  ol  nnnr,- 
i„  n,,,,:uinna,-with  n.o.v  or  Irss  ,.ain  and  .Iwtn'ss  n. 
thr  hark  Tlu'iv  is  vrrv  f.v.,nrnt  aiul  |.aint.d  inirtuntioii, 
,,•„,,  „H.  rassauv  of  only  a  f.w  dro,.s  of  Idoody  nnm-,  ot 
l,i.,.l,  .n....iti..  -ravitv  an.l  i-ontainin-  hlo.Hl-..or,M,srU-s  aijd 
tnhr-.asts.  On  hoilin-,  tlu-  uriiu'  luTon.rs  almost  soli,  m 
tlK-tnhi'.  Th.'  o..lrn,a  ahont  tlu-  I'y.'s  is  viTy  ....tni.al.l.', 
and  is  soon  f -llowf.l  liy  dro|isy. 

This  is  th.'  form  ..f  a.Mitr  intlaniniation  ol  tlu-  knln.'y 
that   is  most  lik.'ly  r..  t.-nninati'   nipi-Uy  m  .h'atli,  ..ll.'U 

ni'ovini:  fatal  in  a  f.'W  days.  _ 

If  howrviT,  tin- .-asc -.'.'son,  an.l  tin-  i.nm-  is  not  voidi'd 
in  .Mvatcr  .,nantitv,  still  .Mmtainin-  hlo-Ml-capsnlcs  an.l  no 
h.ss  allmnu'ii,  th.'  .lis.'asi'  nia.v  tiTiniiiati'  in  ahsross;  or, 
if  all  till'  symptoms  inii.rovi',lii'a.larlii'  an.l  naiisi'a  lu'.-oiii- 
i„.r  h.<s,  th.'  nriiu'  in.ri'asin.i;  in  .luantity,  an.l  ti'ViT  std.- 
,i;H„.._tlu'  ki.liu'V  may  so..n  hi'.-.>nii'  ..f  tlu'  hir-.-  wliiti- 
varii'tv  and  tin'  .asi'  tiTininati'  in  m-ovrry,  in  .hroHK- 
tuhuhu  tu'i-hritis,  or  possihly  in  inti-rtnhnlar  iii'i.hntis,.|iist 
as  i.iH'nm..nia  may  omisLmally  end  in  i-ut1k.sis  .d  tiie 

""vhout  thm'  voars  asfo  T  was  cnll.'d  to  soo  a  patii'iit,  a 
stevo.l.,ri',  who/whili'  workin-  vory  hanl  in  tlii'  hold  ot  a 
shii.,  and  w.'arin-  hut  little  i-hithin-  ami  iKTspinn-  Iri'.'ly, 
had  .•OHIO  ..).  on  .l.'.'k  mi.l  sto.ul  tWr  a  few  minut.s  m  a 
cold,  .lamp  win.l.  He  was  alnn.st  ininu'.hately  sei/ed 
with  a  severe  ehill,  ae.'onipanie.l  hy  voniitmir.  His  h'l- 
l„w-worknieii  sent  him  lionu-  in  a  .'arna.ir,.,  ami  I  saw  hini 
a  few  honrs  later.  His  temperatni-.'  was  l(l4  1< .  H.' 
eomi.laine.l  of  severe  heudaehe,  eoiistant  v..mit,i.g,  great 


— '"    ■' 


106 


i>isi:.isi:x  '>r  Tin:  a/d.vkjn. 


|.!lill    illiollt     tlir    1.11.  U    1111.1    .l..\VM    the    U-V.-ill.   1111.1    11    most 

iH'cnliiii-  .Ivspii.i'ii.  II.'  .viis  .•..iist:iiitly  .•ii.l.'iiv..riii,ii-  t.. 
urituit.'.  iiiiil  lit  ciU'li  ctlnrt  piisscl  al..)ut  ii  liiilt'-t.'iisi.<H.nfiil 
,,f  l.l.MMiv  uriii.'.  Til.'  lu'Nt  'lay  li.'  still  .•..nii.liiiiu'.l  of 
lit'iiiltu'li.'  1111. 1  nausea,  his  t.Mni.cratiiiv  .•..iitiii.U'.l  lii-li.  an. I 
tlifff  w  a>  v.TV  little  ill. Tease  in  llie  aiiiouiit  of  mine,  w  lii.'li 
still  e.intaiiieil   M.i.nl. 

N..t\\itlistan.lin.ir  tlie  I'a.M  that  I  apiK'nle.!  t..  th.'  skin 
aii.l  l...\vels  to  assist  the  ki.liH'Vs.  .Mipi.e.!  him  ..ver  the 
h.ins,  an.l  inii.h'  I'Very  etlort  t..  ivlieve  his  he  i.laelu'  iiinl 
nausea,  the  >ynii.t..nis  wei'e  very  litlh'  mititi-at.  <l.  Dr.'i.sy 
iipiieare.!.  an.l  lu'  d'wd  on  llu'  tiflh  .lay. 

On  |M.st-niortem.the  ki.lneys  were  t'ound  vei-y  lar^'e  an.l 
re.l.  the  eai.siile  sti'ii>i>in^;  easily,  ami  a  tVe.'  ...-/iiiu'  .>f 
1,1. mmI  .m  the  .'lit  siirfaees.  Thi-  tihiviis  tissue  was  swolh'n, 
im.l  th.'  Mali-i.u'hian  ho.lies  .•oiild  Ik- seen  with  th.'  luike.l 
eve.  'riieri'  was  a  eoini.lete  exii.liitioii  into  the  tnhiiles 
anil  iiitertiihuliir  siuiees.  In  other  wonls,  tlu'  ease  was 
one  of  a  thoroiiirhly  lu-putizi'd  kidney. 

I'lUMiNosis.— We"  havi-  already  seen  that  .-ases  may  ter- 
minate in  (U-iith,  ahseess,  or  ehronic  tnhular  nephritis: 
nevertheless  I  have  attended  cast-s  in  whi.-h,  fr..in  the 
syinpt..ms  exhihited,  I  ha.l  every  reas..n  to  helieve  the 
ati"e.-ti..n  to  hv  nephritis  rather  than  tuhnlitis,  yet  whh'h 
ond.-.l  in  |.erfeet  reeovi'ry  in  from  four  t.)  twelve  or  six- 

tei'll  weeks. 

'rni:AT.MKNT.-  -Th*-  treatment  of  this  f..rm  of  kidiu'y- 
inrtammati..n  is  th.^  saiiu'  as  that  whi.-li  has  heeii  dii'i'.-te.l 
for  a.'ute  tuhnlar  nephritis.  In  fa.'t,  we  ean  .1..  nothm,-; 
more  than  has  heeii  ahva.ly  advise.l  in  tuhnlitis,— namely, 
enfor.-ement  of  ivst,  attention  t..  .Hot,  euppin.ir.  an.l  ap- 
iiealins;  to  the  howels  and  tlu-  skin. 


ii 
k 


r 


si  I'l't  i{ATi\i-:  KiPM.y. 


101 


('  11  A  I'TKU    W. 

siiMTUATivi;  K,,.M.;v-\i.s.'i:ss-srinii.'\i,  kilnky. 

\<  1  have  iiliviulv  sai.l,  nut  cViTV  ras..  of  n.-pl'nti^  (<>''- 
f„M'nrnl,ntis).MHlsinal.srt.ss;  l.ut  auv  .as..  Muv.lns..; 
„„,  „,,  ,11  al.s.css.s  tlu-  nsMlt  ..f  .liiVus..  ,H.|.l.nt.s.  M.ny 
j„,  tlu-  ivsult  ..fa  ri.v.n..s.Til.nl  i„tlimn.iat.o„  svlnrl,  M 
,l,u.  to  variniH  .•a,isrs,-iM,)ury  or  wo.m.ls,  infa.vtioi.s,  tlu' 
ro.uU  ..f  .lisrasr.l  ai-tcTU-s  or  iiy|K.nv.ui.'  intlaimiialions, 
.-ravrl,  a.MH.sits  in  thr  tul.nlvs,  cMnLolisnis,  pvaMnia,  sup- 
;.n.ativr  pwlitis  or  ryslitis  will,  or  withont  stn-tnr.-  -t 
tlK-  urvtl.ra,  tuhm-ulosis.  an.l  s..n,fnlous  ki.lnrv.  One-  ..r 
l.oth  ki(lni-vs  may  l>i'  inv(.lvc.l. 

TUv  al.^.Vssi.s  n.av  1...  very  small  an.l  nnn.rr....s,  .m.m- 
tin...l  nu.r..  ,.arti.-..larly  to  tlu'  ...rtL-al  portmn  ..r  th.y 
„.ay  coaU'soo,  .oavertin-  n.arly  tin-  whole-    Uwhu-y  mtu 

on.'  lairulinit  mass. 

The  tul.rr.-ular  ki<liu.\ .  while-  ri.l.llcl  with  al.s.-..ssv>, 
.litl-ors  in  its  .■ti..l..iry,  l.ath.,l.W.  symi.t..n.s,  an.l  pr..- 
„osi.  Whrn  the  al.s.vsses  are  snmll  ami  s.'attero.l,  t he 
other  iM.rtions  ..f  the  ki.lney  are  likely  t..  j-ieseut  the 
charaeteristies  of  tuhulitis  ..r  intertuhnlar  nephritis 

j),„j^.osis.— It  is  ii..t  iM.ssil.le  t.)  .lia.unDse  small  seat- 
toiv.l  ahseesses  in  the  ki.lney  while  ther.-  is  no  pus 
.soipin-  with  the  nrine:  an.l  when  there  is  pus  u.  the 
urine  it  is  sometinu-s  .litlienlt  t..  say  whether  it  .l..es  ..r 
iloi-s  not  e.)nu-  tVoin  a  pyelitis  or  a  .-ystitis. 

\.  a  rule,  Imwc-ver,  a  eorreet  .lia-n..sis  ean  he  ma.le 
from  the  historv  of  the  ease,  the  .-omlition  of  the  patient, 
,,  ,areful  examination  of  the  hla.l.ler,  himannal  exaunna- 
ti..n  of  the  ki.lney,  and  analysis  of  the  urine. 


(■       ^: 


I 


ma^ 


lOH 


DisHAsKs  or  Till-:  kipsevs. 


Symptoms. — Tlifn-  will  lie  recurrent  diiils  witli  ft  vit, 
\\\v  iiiovniiciits  1)1"  tlif  ImhIv  cimsiii^'  piiiii  whicli  t'Xtfiuls 
iiloiiir  tin-  liiif  of  ttu'  WYvWv  t(i  till-  -fniiii  nr  tin-  tfstifU-. 
\'(iiiiitiiii;  and  lii'inliiclu-  iiiiiy  In-  prt'si'iit.  'IMu'  uriiu' 
will  111'  irri',u;iiliir  in  (|Miiiitit_v,  (•(iiitiiiiiiii.!;'  |>ii.-<  and  hlootl- 
I'orpuscKs.  Till'  kidncvs  arc  til'trn  I'nlarSp'ctl  and  always 
ti-ndt-T,  wliilc  the  jXiMU'i-al  mnditidii  is  liki-ly  tt>  U-  mndi 
worst'  than  in  a  iivclitis.  It  is  nc<»ssary  to  rtiiHinin'r 
that  wlu'ii  only  one  kiilncy  is  involvfil  pus  may  a|>iK'ar  in 
till'  urini'  paioxysnially. 

pRoiixosis. — A  small  ahsci'ss  may  hv  converted  into  a 
eali'are'ons  mass,  or  nniy  opi-n  into  tin-  jH'lvis  anil  lical. 

I  have  t'oiind  post-mortem  fvidi'iico  ofalisci'ssi's  lavinir 
healed  in  this  way,  U-avinu;  the  kidney  healthy. 

Ahseesses  may  open  into  the  ahdomimd  cavity  and 
ciiuse  death,  or  into  the  cellular  tissue  and  result  in  ex- 
tensive perinephritis;  or  the  whole  kidney  nmy  he  de- 
stroyed, the  patient  dyin^^  from  exhaustion  or  pyiumic 
poisoniiifj;. 

Treatment. — For  the  manatrt-ment  of  abscess  of  the 
kidney,  see  the  cha^tter  on  Suri;ical  Kidney. 


cnAPTKu  yvr. 

TUBERCULAR    KIDNEY— NEIMIROI'IITUISIS— TUBERCULOSIS. 

Inasmuch  as  the  urine  in  this  form  of  kidney  contains 
pus,  the  product  of  the  cheesy  tubercular  intiltrati.)n()f 
the  organ,  it  is  proper  to  consider  it  here  in  connection 
with  supiMiratini;  kidney. 

It  is  seldom  that  we  meet  with  a  primary  tubereuh)sis 
of  the  kidney;  nor  is  it  very  often  that  the  kidney  suffers 
from  a  tubercular  deposit  in  a  general  acute  miliary  tu- 


i-raiyi  ji  .vf  R4';.cpy¥jqyT-^:'urff 


»smKncKsr?5  jwsK*''w«*' 


tlu- 


rriti:ii'  I  i.Mt  Kii^si'.y 


lo'.t 


,     ;,      Thi-  mvatrri.nn.lM.r..ftl..-as,.saivs......,Ml- 

;::,.:;:;;l-:  ,.:;'•> -• i...  .■.i-->vi^- - 

1    .  f,.  iiivdU't'  tho  urinarv  tract. 

''''',.;::.:■.,■..- i ■■•'■"■■if ■■•t'^  ■':,:;■:: 

-n.i,  ,„l„.,v„lur  ki.ln.y  shown  ,..  !■..'.  1-     '    ;'  ^  •  ^  !  ^'^. 

«„..,  „.i,h  a.,.v,  ""■;■■■:,•;";;;;■;';;,„     ;:„.,-„. 

tlnvo  times  the  nonnal  si/r.  and  a>  iiu  .,  i 
lar-lockiiiij  as  the  ki.lnev  itsrlt.  tiwt-u-le^ 

(,„,  or  lu.th  ki.l.u.ys  ,nayl.e  .nv..lve.l.      I    e  t..tuk. 
Jt.   l.la.l.ler    may  In-    attaeke.l  Hrst,  am     tWe  a  s.    >e 
:;j:;i  npwar.1,  or  the  ki.lm-y  may  l.e  atta..k..liu.t,  and 

^^^v'^T:'"r::^^T; -....  tui.en.nio.is  ot- the 

Sv\ii> roM;*. — I"  a  ^«'^^    "■    i  ,  ,.  •        ^.i   . 

!«;,;;;;  ,,11 «?  the  ^m»«ni..,.  tvo„>  .1....  ..t-  ,„«..,„„.»«„, 

caneer,  or  other  new  growth. 


tl'l 


/i/v/;is/>  "/■  Tin:  az/'V/.)  v 


h'l.i  \r>. 


■-VI^  Ik.**', 


TiihtTouliir  ki 
hIm 


X    :;::!:; :h... .Mi......    T),oo.h..rWMo..ywa^-,or '_'-"";-;-'"'" 

i.  n..t  ..tlarwis..  in.i.li.'atr.l.  wr  sl.all  .H-rtaiiily  he- justifuMl 
in  susiKH'tin-  liilK.r.'ulusis  ..f  the  ki.ln.-y  if  tl.e  ..i-an  is 


n  r.i:i;rn.  \i:  kiI'M:). 


II 


i;;;;.:„.na    a.   tl...  fi.M    -un, Un.    un.,)    n  1 ^ 


III 

III 


,.,in..    w....;i.in...  l.-'.r.ai.M.r,l,...lu.i..M....    ul...,..nb 

.•..     1,;  with. Lis  ....n.li.i..n,.li..l.l:nl-."l ..n.:^ 

i..i;....,.,l...  ...i.l.-sl inlil.ia...Ul..n.w,ll.. 

M-..^iinloM...rl..aiiv.l..ul..al.,.u,  .h,..l,a,..i.M.       Ii 

;^!.     ,..w..v..r.ui.l.wi.i.liu.. .■.v.,i..n.  > ='^ 

.:     •:.   ,ul....vMla, ..li.i.moni...  ..M,..l..M...ria, 

....nl...>.-i.in:.l-si.l.swi.Usul im.M.  ,ul.,.,v,il..M. 


of  tlu'  kitlix'V. 


"'t     ;;      litS rniii..^  ,Ml,anlKl.....n.aU..n. 

,„..„,„,  ,i....  .x.,„   ..an...-.      ^V..  .ia.ul.l  -...,. _-t 
,:..,..U.aHintla,..n.a,i..Mwi,i...ut,i.l...r..ul..>M    .;     ..'I^^^ 

,1  v,l,  tW  lu-in..  n.av  1..  ,...H-tly  <.I-.^  -  w^^ 
:;:,l.;nins,..al<in,or.i.,,u..a,in.l<,an..v,..,.us^^ 
,,.,^,.i„,lH.nnn..,.M-l.a,.s.a.v..v.|.v.u..o     1     .   ...^^ 
'    Tl.isismon.  liU..lyt..  .M...|.rintulKT..ulark.ln..     tlun 
in    •n,,,.u•a.in.^  n.M.4..1iHvu!a,-  ki.ln..    sn,....  .1...  lun...n 

„    '  „,„.,,   is    n..t    ..   lik..ly  ,..   1...   K.ss..n...     a._  in      .. 

,      ...h.,-   van..tv.  wlu...  i.   s.M..n.    ..s..a,..s    liav.n^  .W 

...   ,ul...,....na,-..l.anu.n.ras,l,..   ki.lii..van.lus,...lv,s. 


(it 
ti 


iilatf  in  <|iiantily  sntH- 


,,u.  until   tl...  m.iii..aii.ll.i.sa,-.Mnn.  wm,  „,,  ,„. 

.•„.,„  t..lo|.....tlH.  l.usthn.u-l.t..  til- l.la.Mof.     \    1....   til 

^1 lula.->...n....nvisla,...ly.l..--.-';l,-..-al.^^^^^^^^^ 

;,  ,v...k   tnay  flaps.   l...t.Mv   any  ufuu.  tn.m    th..   .l.Ma>..l 

ki.liuv  foaclu's  tho  lihuMi-r. 

;  .S..S..S.-W.  hav.  ahva.ly  s.cn  un.l.r  wl.at  ....•..un.- 
,JJ:;,;,   ,.,,,.  i„.,..ssil.,..t.M.ik.aaUU..nn^^ 


uosis  in  tlu-  rarliiT  statri's 


Manv  cases  of  brokfii-.l.'wn. 


:,r.;M,-„...l  ki.ln,,vi„  ..■r,.f..l....«  ,.a,U.n.s  ,,:,..  t.r  ,.,« 
„f;„Wr..nl,..R     Wlu.„,l,...lis..„s,.i..-..nh 1  .„  .1...  k„l. 


i 


^,.j  /)/>/  is7;s  or  Tin:  i<ii>M:ys 

„..v  „.,t  .v.n  i.UH/.nL'  .l"VM'  u,iii.|.li.i>tini.'tl.-"r.-t.T.  it 
i.'nnt  lik.-lvtu  1...  t.,lM.,vulu>i..  In  ll..-stn.u.o„..a..-H 
,1...  .li.nr-.'imi/MtiuM  i.nHM.r.U  tVuM,  a  i-vl.ti.  .r  a  I'vn- 
„,,,1„..M-.  svl.il.' III.' tMlH.r.Mlar.l.r-^""'*'"'' I""""-' >  """ 

,1 rli.'ul  iM.i'tinM  ..f  tl..'  Ui.ln.'V  ..!•  > ...Ian  K.  tulM..'.'..- 

l.„.  .l..,,M~its  .'ImwIi.  T.-.  r,     1     ,     I 

,„  ,1,.,  I;,,..,-  >ta-.'^  t.ilM.iv.ilar  Ui.ln.'.v  i-  imt  liU.'l.v  I..  1'.' 

n,i.|;.l.-..  I'..r  imvtl.in-  Imt  s..|.im''^"'"-'  •^'"''"■>  ;""  '•;'.";'■''• 
K,„.  ,1,..  ,li,.irn..-*iH..rHUi.i.iiratiiiLM.Mi.-tulM.iTiihn'  ki'ln.N 
vvr -iH.ul.l  l.;.N.' to  .l.'p.'n.l  Mu  tl..-  I.-Ht..rv  ..f  tiK' .'u-'.  an.l 

l,u.ur..lv..n    tl mliti !•  tl..'  pati-'Mt.  if  w.-  l...n..l  no 

,,vi.|.'U.-..ftMl..r.l.'ina..y..tli.'ri.art  -I   tl..' IhhI.v 

-n...  „uM-.'xiM.'i..'.-..fir.'i>"fal  t..lM.i'.ul..M<WMMl.l  al-.  I..- 
,^,,  ^.,,.,„,,,„  •„,  ,1,.,  .Ih.iriH.sis  ..r  .an.'.T,  whil.'  .'n.a.tatwm 
.,„.l  ,;,„.•.. n.,M  .•a.'h.'xiaw.Hil.l  assist  in  .'..Mlinmn./  it. 

1,  i.  I,ar.'lv  iH.ssil.l,.  in  s.m..-  .'a<.'s  f-  .li..'..v.'.'  iuI.-t- 
..K.-l.a.'illi  in"  tl..  ...in.'.  This  fa.'.  .aMM.-t  !.■  .l.'l..'...M 
„,...„  as  ..fn,...'lMli'a.un...sti.'valM'.      1.  has  1......  .u-.sU'. 

„;^„    ,„-„„,l,    n.iLTht    1..'    iM...'ulat...l    wUh    th.'    s.,-., .'.1 

„,i,u-.    whi.h,    if    ha.illi    UV.V    i.r.'M'nt.    w.ml.l    .U'V.'L.l. 

tilh.'i'rilhisis.  ,.    .         .  1'         I 

l.„„..^.,.m  —n.l.'ss  th.-  tuh.T.'.llai'  .'n|..|ltl..n  IS  .'..Mhll.-I 

t.,..n.'  Ui.ln.'V.  tl,.-l.r..irn..sis  will,  of  .•..u.'s.'J.rl.a.l       In 

......  v,.u  a.v  iWrtunat..  .'^.o-v^h  to  n.ak.'  th.-  .l.airnns.s  whik' 

,1„  ."liM.as..  is  i-riniarv  an.l  whil.'  ..nl.v  ..n.'  knUu-v  is  ui- 
v.lv.-.l.  tlu"  .v.noval  ..f  tl..-  ki.'M..y  u..ul.l  ..f  .'.Mifsr  n.ak.' 
thi'  i.rotrn.isis  in.>r.'  favorahlc 

'P;^,,^.,.„,.^•,..— Wh. c."  th.-  .lisi-asv  is  .-..nhn.'.l  t..on.'  ki.l- 
H..V  nn,..val  is  th.-  ..nl.v  n-un-lv.  Th.-  .'..n.lit.uns  t..r 
sui'h  r.'n.oval  w  shall  la-rouu-  a.Miuainti'.l  with  n.  th.- 
l,.,tm'.'  .'n  siiriri.'al  ki.ln.'.v. 

Wl,..,-..  oih.-r  or-ans  an-  involv.-l  t..  sn.'h  an  .-xt.-nt  as 
to  n.ako  an  o,K-ration  n..,ins.iiial.l.',  w.  n,nsl_runt.-nt  ...u- 
si.lv.'s  with  tmitinir  th.-  syn.pt..ins  as  tlu-y  arise. 


.,_   ^t^i   .'-t*«U.^>»*»* 


f.  Bi#42#.iia*.:i^.aafeH-9«- 


I  n.K.MIA. 


\\'.\ 


Amu  iimtt.r..|iiit.  iv,t  \n\hr  |.iitliM|oi;ir.t  nitluT  tliati  t.. 
til.'  .•liiii'i;!!!.  I  iMMV  iviniirk  tli;il  in  miiiiy  nx^^^  «'!'  |'m1- 
iiiMiuiiv  |.litliir*is  til.'  ki.lii.v-  mv  f'.'im.l  Hlii;lifly  .iiliiru'.-l. 
tlu'.'ii|Hiilrs  thi.U.ii.'.l  an.i  I. ><..»•.  mwl  tlir  .pitli.  limn  in  u 
rttat.'  of  fatty  .l.^'inTatioii.  Tli.-  ««nly  ^yniptuui  of  .li^- 
rasf  that  tln'-f  <•a^••■»  iiianifr^t  .lufiii.if  lilt-  i-*  a  sli.ulit  Ira.r 
of  iill»iini.n  in  til.'  m  ii.'.witli  |MTlia|.ssuiiir  t.iMl.'nicsH,.!! 


('  II  A  I'TKU    \  \   1  I. 

ni.KMlA. 

Uli.KMlA  i-i  a  t.iiii  ai-pli.-l  to  a  .Miulitioii.  siipi-osi'il  to 
Im-  .iiiH.'il  l.y  .liM"iM-4  of  the  ki.lm'ys.  in  wlii.li  tlio-*.-  ..r- 
irans  fail  to  |..Tfonn  tluir  iioriMai  »  ftioii  of fliiniiiatii.n, 
an. I  all..\v  material  to  !..■  .•liininat.-.l  wlii.'li  slmuM  !..•  iv- 
tain.'.l  in  tli.-  I.Io.mI.  It  is  cliara.t.'ri/.'.l  l»y  .ly-on.ra, 
iu'a.la.li.'.  tli/zini'ss,  voniitiiv-r,  .liarrlin'a.  .•onvnl.-i.Hi<,  ami 
foina,  th.'  syni|.toiU(*  varyint;  in  indivi.lnal  .as.s. 

l.;,.,,,i,u,iv.— 'rii.M'ti.)lo,-ry  •>f  iiraMni.'|>oisonin,iri'<'>l"*f>i''*'i 
hut  .•.Ttainly  in  soin.-  .-asi's,  at  l.•a^t,  tlic  synipfoms  art' 
tin.'  to  til.'  non-.'liinination  <•!  fX.Ti'tni'iititioiis  mat.  rials 
l.v  til.'  ki.lii.-ys.  Symptoms  atv  l.nt  tin-  .•xi.n'ssn)ns  of 
patliol.virital  .•omlitions,  and  many  poisons  tak.'ii  into  tliu 
1.1. .n.l  or  jr..norat('.l  tlu-ri-  manif.st  tli.'ir  morl.i.l  .^'tlW'tH 
tlironirli  thf  Itrain  an.l  the  spinal  .onl. 

.Nranv  thi'orics  liav.'  Iiffii  advan.'.'il  as  to  tlic  j.rimary 
raus.'  .".f  this  .-omlition.  It  was  ass.Ttf.l  that  an  cx-.'ss  ..f 
urea  in  th.'  I.Io.mI  pr.xhu'i'tl  nra-mia;  hut  nr.'a  inj.'.t.'d 
int..  th.'  I.Io.mI  was  touml  to  act  ..nly  as  a  diinvtic.  It  was 
als..  maintained  that  urea  wa^  dc'cmposed  in  th.-  1.1. mmI, 
sc'ttiniT  free  carbonate  of  ammonium,  which  acted  as  the 
^h  10* 


t-'^tam^'-vam''-  'J».  v-'SfT'.'!^^'  S'' 


u 


lHsi\iSi:s   OF   Tin:    KIDSF.VS. 


tdxif  iitrt'iit.  Tlii>  iilso  liiis  l-r.'ii  .lisiin.vvd.  Tlu-  tlifory 
\v.\<  Ihiii  ailviin.ril  ilial  tin- ('(.iKlitioii  is  autoirfiK.us,— that 
is.  tlait  tiir  i«>i-(«ii  is  alisoi-hfd  iVoiii  tlu'  aliiiu'iitan  canal. 
Tlif  iii.Thani.al  tiH<.rv.  that  ui'ii'iiiia  is  tin-  ri-siilt  of  (viU'iiia 
(.f  tlic  l>i'aiii,  has  slill  many  ailiu'fi'iits.  llowtviT.  tiir 
(liMiciilty  may  iif  in  tlic  iart  that  in  thv  diseases  u-ivinir 
rise  t(»  this  (•(.iidition  the  di'si|namati(.ii  of  the  enitlielinm 
in  tlie  ttihiiK'S  jn-events  tlie  inannfaetnfe  of  iifea  fiom  the 
various  waste  jUMxhiets.  ami  that  the  tifa'mia  arix'S  lu't  so 
iiiu.^li  from  the  retention  of  Ufea  as  from  laek  of  its  i.fo- 
.Inetioii.  Mo>t  i-foinineiit  amon,<r  these  retaine(l  |iroduets 
are  creatin  and  ei-eatinin. 

Tiie  stronu-  i.rol)aliility  is  that  the  nru'inie  condition  or 
(■onvnl>ion  is  sometimes  the  ri'sult  (.fa  chemical  condition 
of  the  l.lood,  ami  at  other  times  dei.eiids  upon  (edema  of 
the  l.rain  or  etfiision  ;  the  etfusioii  may  he  ventricular  or 

arachnoid. 

\V,'  have  all  seen  how  the  .edema  will  shift  ahout  :  one 
morninu-.  in  a  case  of  I'.ri.ijhfs,  we  tind  (I'deiua  perhaps 
of  tlie  arm.  while  the  next  day  it  may  he  in  the  dottis  or 
he  contined  entirely  to  the  lunii-s.  1  have  m.t  the  sli-rhtest 
(h.uht  that  some  of  the  cases  of  so-called  iinvinic  convnl- 
Kimis  are  tlu-  result  of  (edema  or  etVusion. 

This  theory  has  heen  supplemented  hy  lluirhlin.irs  Jack- 
son ami  Uosenstein,  who  have  suLT-Ti'^ted  that  the  initial 
ehantiv  is  spasm  of  the  cerehral  hlood-vessels,  leading,'  to 
convulsions  hy  cuttin,-r  oil*  the  hlood-supply,  and  followed 
l»v  effusion  it'.o  the  lymph-spaces  of  the  hrain. 

While  it  is  possihle  that  some  cases  of  so-called  uriemic 
nmvulsions  are  due  to  .edema  of  the  hrain  or  suhara.di- 
noid  etfusion,  it  must  n..t  he  fortrottet»  that  nephriti(' dis- 
eases otteii  produce  nutritive  disturhances  either  of  tho 
br;'in  or  the  memhranes  or  of  hotlu  and  that  the  convid- 
sions   mav  he   due   to   these   i\utritive  lesions.      In   fact,  I 


!W?S«S^.  ja»*»!)»KUe6*V^SSi^^  ■ 


mm 


1  li.lMIA 


115 


lu'lit'Vc  it  iiiiiv  lie  liri)ii(lly  stutcil  that,  willi  the  .■xcfption 
of  till'  kidiicv  itscll'.  Ill)  (iriraii  is  iiion-  liUi'ly  tliaii  tin-  lirniii 
to  siiIUt  nutritive  lrsioii>  diiriiiij;  tlic  coiirsi'  of  iici>liriti«' 
(lisi'iiscs;  and  it  is  t'oily  to  attrilmtc  I'vcrv  case  of  coiiviil- 
sioiis  tliat  oiciirs  in  tlii-se  disi-ast-s  to  a  |iatliolo<i-iial  tln'ini- 
cal  conditio'    of  tlir  Mood. 

Not  lonu  .int'i'  I  was  caliiil  in  consultation  to  sec  a 
voiiii,!;  man,  a  medical  student,  who  was  in  violent  con- 
vulsions. His  attendinu-  p'.iysician  said  that  he  had  had  a 
severe  chill  two  days  liefoi'e.  which  ushered  in  a  pneu- 
inonia.  On  iii(|uiry  as  to  the  condition  of  the  kiilneys,  I 
was  told  that  tlu're  was  \\i>  allnuiieii  nor  any  imlication  of 
nephritis.  I  soon  leanu'd  from  the  yoiin.u:  nian"s  mother 
that  he  had  siitl'ered  with  an  attack  of  meiiin,Lfitis  a  year 
and  a  half  hefore,  from  which  his  father,  who  was  a 
phvsician,  tliou.trht  he  had  never  entirely  recovered. 

ills  convulsions  were  (•ontn)lled  only  for  the  time  hy 
chloroform,  and  he  soon  dii'd.  I  ohtaiiu'(l  a  post-inorti'in, 
at  which  the  meniniri's  were  found  to  1h'  connvsted  and 
infiltrated  with  serum  and  pus,  with  adhesions  :dtout  tlio 
middle  of  the  longitudinal  fissure,  the  hrain  showini;  ii 
trranular  roujrheiu'd  comlition  eorrespondintr  to  tliat  pro- 
duced hy  calcareous  deposits  at  the  hase  of  the  falx  eeri'hri. 

Had  this  case  heeii  one  of  nei>hritis  instead  of  pneu- 
monia, the  convulsions  would  undouhti'dly  havi'  heeii 
eallctl  unvmic,  a  post-mortem  wouhl  have  heon  considered 
unnecessary,  and  the  hrain-lesion  would  never  have  heeii 
discovered. 

It  has  occurred  t.)  nu'  that  it  is  possihle  for  at  least  some 
of  the  cases  of  so-called  iiriemia  ti)  he  the  result  of  poison- 
ous animal  alkaloi<ls, — viz.,  ptomaines  or  h'liconiaines. 
These  poisonous  chemical  suhstances  have  heen  shown  to 
consist  of  decomposed  alhuminoid  matter. 

The  study  of  these  poi^ous  is  only  in  its  infancy,  and  is, 


r 


11  fi 


/</.vAMv/>  or  THE  i<msi:yx. 


!  t 

Bi  t 


» 


no  (liMilit,  (lotiin'fl  to  r\|.l;rm  itiiiiiv  not  y>'t  wi'll-iiiultT- 

Stoixl  septic  (•(•llditinlis.  It  is  proliilMf  tllllt  solllr  of  tilt! 
|itoiiiiiiiit>  iiiT  tlic  imlirrct  n'suit  of  miiToln's,  tin-  :ill»u- 
iniiioii'  (IccoiiiiM.siiioii  Ufiiiir  set  ii|>  liy  tlu'ir  i»ffsi'iict' : 
wliilf  tlif  Iciii-oiiiaiiifs  arc  tlu-  n'siilt  <»f  tin-  all>iiiiuii(>itl 
(K-.(.iiii.o.-.ili(.ii  sft  up  Ity  tlu'  pivsi-iKv  in  llic  liloml  of 
rln'iniriil  materials  dut-  to  tin-  iiii'taiiiorpliosis  ot"  tissue. 
This  pliysiolouical  jn-occss  of  tissui'-\vast»-  is,  of  course, 
iiices.-ant.  and  kei'ps  up  tlic  ireiieratioii  of  products  tliat 
should  he  eliiuinatetl, — products  whose  retention  has  hceii 
hIiowu  to  set  up  iilhuniinoid  di'coniposition,  producini; 
material  ot'  a  hi<!;hly  pois(tnous  nature. 

It  can  t'a.sily  he  seen  how  even  functional  dcrauircment 
of  an  important  I'liminative  ortran  may  pioduce  the  most 
serious  restdts,  and  that  organic  disease  of  the  ort;an  must 
eventually  prove  tiital. 

[n  suddon  suppression  of  th  function  of  elimination  hy 
the  skin  or  hy  that  <;reat  eliminative  oriran.  the  liver,  wo 
have  examitles  every  day  <)f  poisonous  accumulations  in 
the  hlood,  no  douht  the  result  of  alhuminoid  decomposi- 
tion due  to  the  presence  of  retainecl  metamorphic  ma- 
terial. 

Patients  with  tuhular  nciihritis  hecoi  e  aiiiemic  very 
rapidly,  and  the  disintejrration  of  the  red  hlood-corpuscles 
may  in  some  cases  manifest  its  deleterious  effects  on  the 
nervous  system  hy  uru'inic  symptoms. 

Symptoms. — You  will  find  in  some  of  your  text-hooks 
a  irreat  variety  of  sym[>toms  attrihnted  to  unemic  poison- 
inir.  Many  of  these  symptoms,  howi'ver,  are  the  result 
of  the  ansemia  and  other  diseased  conditions  rather  than 
of  the  unemia.  while  some  are  no  douht  the  direct  result 
of  the  urienuc  poisonin<r. 

The  so-called  unemic  convulsions  are  epileptoid  in  their 
character,  and  in  fact  in  some  cases  it  wyuld  he  impossi- 


■i»IHJl'r!IJJ'l-'!!,''.ll'^',! 


1 


nt.KMIA. 


117 


Itli'  to  <listiii,t;uis]i  tlu'in  trmii  ciiilcptic  attacks.  As  a  nili", 
till'  patients  ill  iiia'iiiic  coiivulsioiis  ar*-  not  so  iirofoiuiillv 
unconscious  as  tiiosc  in  cpili'|isv.  Tlicy  will  often  injuri' 
tiicir  tont^ucs,  and  simulate  \vy\  closclv  an  cpili'iitic  at- 
tack. If  a  liistory  of  tlie  case  could  l>i'  olitaincil,  it  would 
Ite  of  <;reat  assistance  in  diai(nosis,  <  lier  cases  of  iira'inic 
convulsions  very  cl(»sely  n'setnl>.  .ttacks  of  apnplexy, 
even  to  the  proilucin<r  of  a  ]tartial  paralysis  of  oni'  side. 
In  ajioplcxy  tlie  patient  will  almost  always  turn  the  head 
with  convulsive  twitchinijs  to  the  side  of  the  hcinorrliau;*', 
and  1!!  njany  cases  the  teiniteraturi'  will  rise  to  104°- 
1().'»°  F.,  hoth  of  which  syniittoius  are  not  present  in 
uneniic  convulsions.  I  have  never  st'cn  a  patient  live 
more  than  a  few  hours  when  the  tejujterature  rose  to 
10.")°  itnniediatcly  aftt-r  the  apoplexy. 

We  (tfti'ii  ohservo  a  dropsical  condition  of  the  patient, 
which  would  indicate  ura'mic  poisonini,'  rather  than  apo- 
plexv;  and  on  drawinu:  the  urine  in  doubtful  casi's  the 
indicaticui  would  bo  stren_i;theni'd  if  we  found  albumen. 
In  some  oases  of  uni'mio  jioi-soninsj:  which  resemble  cases 
<»f  epilepsy  or  apoplexy  the  patient  may  have  no  o'dema, 
and  albumen  nniy  be  absent,  or  i)o  present  in  only  a 
very  small  (piantity,  the  easoH  being  th(»so  of  interstitial 
or  j;onty  nephritis. 

Hysteria  is  an(»ther  condition  from  wliich  urirmic  con- 
vulsions must  bo  ditierentiate<l.  In  hysteria  the  pupils, 
pulse,  and  temperature  remain  normal,  and  tin'  patient  is 
always  conscious,  while  the  irreiriilar,  jerky  movementH, 
the  spasmodic  respiration,  and  the  chokini;  sensation  so 
often  pn'sent  in  hysteria  are  absent  in  unemic  convul- 
sions. 

Airain,  the  urivmic  poisoninj^  nniy  assume  a  comatose 
form,  and  closely  resemble  opium-poisonini;.  If  nothini!: 
is  known  of  the  historv  of  the  case,  we  may  judijre  par- 


L 


r 


118 


I)Isi:as/:s  di'  tiii:  i\ii>M:is. 


tiiillv  Iroin  tlif  ((niditiuii  of  tin'  |Mi|iils,  wliidi  ar»'  tinuly 
(•imlfactiMl  ill  n|.iiiiii-|>ni>imiiiir  (I  Imvi'.  liowi-vt-r,  smi 
tlu'iii  (liMs  ciiiilriictcil  ill  iiiii'iiiia),  \>y  llif  slow  rcs|iiratii>M, 
ami  I'.v  tlrawiiijr  llic  uriin'  troin  tin-  lilail4tr  and  cxamiii- 
iiiir  il  toi'  alliuiiirii  and  casts. 

Of  till'  tillitT  svmiitoias  oftfii  allriliiitcfl  to  iiriciiiir 
|»(iis(>niiiir,  siirii  as  severe  attaelss  of  tliarrlKCM,  vniuitiiiir, 
astliiiiii,  aiiiiilvopia,  intense  lii'adai'lie,  and  extreme  re>t- 
lessiiess  and  nervuiisiiess,  it  is  verv  liard  to  say  exactly 
liow  niiicli  is  due  to  aiisoliite  ura-mic  iioisoniim',  and  liow 
iiiiieli  to  tlie  circulation  of  other  retaincil  or  alisorlied 
matters  in  tlie  idood.  The  headache  may  he  due  to 
nniiMnia,  or  to  oriranie  lesions,  and  the  vomiliiii:-,  as  well 
as  the  diairhd'a,  to  j^astfaluia  |iroduced  hy  indiirestioii  or 
other  causes. 

TuKATMDNT. — The  indications  for  treatment  when  the 
Kvni|itoms  are  not  very  iirirent  are  to  remove  the  cause. 
Ill  very  nrireiit  cases,  attended  hy  convulsions  and  coma, 
the  relief  of  the  syiniitoins  demands  our  lirst  attention. 

For  the  relief  of  thi"  spasm,  ciiloroforin  or  «'tlu'r  iriveii 
Ity  inhalation  is  usually  more  )iroin|)t  and  in  some  eases 
safer  than  the  hy|iodermic  injection  ()f  morithiiu'.  There 
is  a  ireiieral  im|iression  in  the  jtrotessioii,  the  ri-sult  ot 
oxperieiiee,  that  patients  lahorinii'  under  alhuininuria  are 
extremely  sensitivi'  to  oiiiiiin  ami  its  alkaloids. 

llaviiii;  allayed  the  spasm  hy  means  of  chloroform, 
otlii'r.  or  the  hypodermic  injecti<tn  of  mori»hine,  the 
jiroinpt  evaiMiation  of  the  howels  is  the  siiri'st  iiu'thod  of 
securinir  more  than  temporary  reru-f.  In  fact,  the  ndief 
fre(|iieiitly  ohtained  from  the  evacuation  of  tlie  howt'ls, 
vvi'U  where  no  iTi'i'iit  drojisy  I'xists,  would  seem  to  indicate 
that  the  poison  was  heiiiif  absorhi'd  from  the  alimentary 
tract,  or  was  n-adily  eliminated  througii  that  channel. 
In  our  effort  to  iiuhiee  the  kidneys,  in  this  disease,  to 


I  II. KM  I. i 


— I 


flimiiiiitc  tlic  |>iiisiiii,  we  iirt'  too  dt'tcii  (lisji|i|i(iiiitttl  in  tlic 
iirtii)ii  of  diiiiTtus ;  1)111  \vc  sliiiiild  iifvcr  Ihil,  in  inldilion 
t(i  till'  use  (»r  cathartic  ini'dicinc,  to  ii|i|icid  t(»  tin'  sUin. 
cillicr  hy  tin'  liyiMxIcrniic  use  ot"  |iil()Ciir|(iin'  or  \>\  otln-r 
activt-  diaphoretics.  Hot  air  is  iisnally  i|nitc  sate,  ami  is 
always  a  sure  means  of  prodiicini;  active  dia|ilniri'sis. 
The  jtaticnt  can  he  |ilaced  in  a  canc-lKtttoiiietl  chair,  siir- 
ronndetl  l>y  hlaidxcts,  ami  liy  im-ans  ot'an  alccdnd  laiiMi  or 
hv  the  crmler  method  ot"  Imrnini;  alcohol  in  a  sancer, 
called  in  coinimm  parlanee  "  nun  sweat,"  the  desire<l 
I'tlect  can  he  |in)duci'(l.  The  ordinary  hot-air  a|t|iaratu.s 
is  the  most  convenient  and  etKcit  nt  it' we  have  it  at  hand. 
Of  the  cathartics,  tin-  saliiu's  serve  the  hest  imrpose, 
eX(H'|it  where  coma  is  present,  in  which  case,  the  patient 
lieiiiiT  unahle  to  swallow,  we  resort  to  a  tew  di^ps  of  cro- 
ton  oil  plaeetl  on  the  toiiLTne,  or  to  urain  doses  of  calomel 
administered  every  half-honr  in  the  same  manner. 

It  may,  in  addition,  he  necessary  to  resort  to  stimulants, 
which  slntnld  he  alcoholic  rather  than  pri'parations  of 
ammonia.  While  I  am  hy  no  means  sure  that  ammonia 
is  di'trimental,  still,  as  we  have  no  definite  knowledi^e 
that  it  is  not  om'  of  the  iiii^n-dieuts  of  the  toxic  aLTeiit,  it 
is  Well  to  avoitl  its  administration. 

Ilavintj  relioved  the  patient  hy  tln'se  means,  the  very 
Htrictest  diet  is  necessary,  milk,  rice,  etc.,  and  the  elimi- 
natiniT  origans — viz.,  the  howels,  the  skin,  and  the  kidneys 
— nnist  he  kejit  in  the  hest  possihie  condition,  relyiiii? 
principally  upon  the  howels  and  the  skin  when  dinn'tics 
are  contra-indicated  or  when  they  fail  to  stimulate  the 
kidnevs  to  activitv. 


r 


120 


Disr.Asr.s  or  the  kidsevs. 


('H.\I»TKI{    X'VIir. 


i^l 


DKdEXEKATIONS — A.MVlJiIH    DKilKNKUATlttN — I.AllU.VCKOl'S    OK 

WA.^Y    KIUNKY. 

Ii'  \vc  wislicd  to  i-liissilV  iis  iiitliiiiiiiiatorv  all  tin-  discjisis 
Mt'tlic  kidiicv  wli'uli  yr\\\.  cuii-.tiiiit  allmiiiiiiuriii,  uc  sIhuiM 
lie  (iM'mcd  ttt  iiicliidf  aiii.vloid  dfi^ciicratioii :  and  tlicrt' 
arc  writers  wild  cuiisidfr  aiiivluid  dcu'i'iuTatioii  an  iiitlaiii- 
iiiatiiiii. 

Difkiiisoii  ('(tiisidirs  uiidir  the  lirad  of  allniiirumria  all 
till'  (lisi'iisi's  wliicli  u:ivo  constant  all)unu'n.  However,  in 
tills  <'oinieetion  wi'  shall  <'online  the  intlanirnatorv  diseases 
to  one  section,  and  consider  anivloid  and  tiitty  kitliiev  us 
de<;enerations. 

Erioi,ii(iv. — The  etiuloiry  ot"  amyloid  deueneration  is,  in 
a  nieasnrc,  limited, — most  cases  lieiiiLj  the  result  of  chronic 
supiMiralion, — from  tiihercnlosis  of  the  lunirs,  from  dis- 
eased lioiK's  or  cartilat;i's,  tVom  old  sinuses,  tVom  loni;- 
discliaririiiu:  empyi'mas,  or  from  chronic  ulcerations  of 
whatever  nature.  Syphilis  is  also  an  etioloijieal  factor, 
and  |ierha|is  some  of  the  Mood  tjlandular  disiasi's  are 
causes  of  it. 

The  excessive  use  of  mercury  may  also  <;ive  rise  to  it; 
whil"  occasionally  in  chronic  tul»ular  nephritis  we  find 
sliirht  amyloid  exudation. 

l*ATiloi,oiiV. — .\myloid  de<;eneration  always  ln'iriiis  in 
the  hlood-vt'ssels,  ajid  is  first  notici-ahle  in  the  vessels  of 
the  Malpiii'hian  tufts.  The  chemical  nature  of  this  exu- 
dation is  not  (U'tiniti'ly  known,  hut  it  receives  its  name 
from  its  peculiar  reaction  with  iodine  and  sulplniric  acid, 
whieli  is  identical  with  that  of  starch.    It  is  called  "  waxv  " 


itott 


1 


DEGEXEHATIitSS. 


121 


lu'canso  of  itrt  ]H'<'iiliiU'  iippcaranii'  wlioii  cut.  Aiiiyli>iil 
(K'UTiu'nitioii  i-<  not  otU'ii,  pfrliaiis  is  lu'vcr,  strifllv  >'<'m. 
tiinil  to  till'  kidney,  Imt  involves  otlu-r  orLrans,  i's|n'cially 
tlie  liver,  the  lynipliatie  jrlands,  and  the  hhx.d-vessels  of 
thi'  niueous  iiu'Uihrane  of  the  stoniaeii  and  howels. 

We  find  tile  kidneys  niiieli  enlart;ed,  ami,  when  eiit 
into,  preseiitinLC  a  waxy  or  lar<i.iee(iMs  appearance,  ratiier 
dry,  with  very  little  hlood  on  the  surface. 

I'pon  the  application  of  iodine  and  sulphuric  acid  to 
the  cut  surface  the  characteristic  reaction  appears;  with 
the  former,  the  di'posit  assumes  a  reddish  maroon  color, 
and  with  both,  a  violet  appearance. 

The  epithelium  linin,ir  the  tuhules  suffers  less  than  in 
any  of  the  inilanimatory  conditions  of  the  kidney. 

"SvMi'ToMS. — As  amyloid  de,irciierati(»n  is  not  contiiietl 
to  the  kidneys  and  is  secondary  to  other  chronic  diseases, 
the  ,srcnenil  exhausted  condition  of  the  patient  cannot  he 
attrihuted  t(»  this  disease  of  the  kidneys.  The  special 
synijitom  oxhihited  hy  the  ki<lneys  is  their  enlari,'emcnt 
with  some  tenderness;  hut  the  characteristic  feature  is  an 
excessive  quantity  of  urine  containini;  alhumcn  in  lari^e 
(luantities.  AVhen  we  find  a  patient  who  is  the  subject 
of  chronic  suppuration  or  has  a  history  of  syphilis  with 
enlarircment  of  the  liver  and  kidney  and  who  is  makin<r 
a  lariTc  (piantity  of  allmminous  urine,  we  may  l>e  sure  that 
we  are  dealini;  with  a  casi'  of  aniyloi<l  dejreneiation. 

DiAtiXOSls.— The  dia,<rnosis  of  this  form  of  alhuminuria 
depends  upon  the  imjtiication  of  other  orsrans  and  the  his- 
•torv  of  the  ease  to  <listinjiM'ish  it  from  other  forms  of 
enlargement  of  the  kidney  or  polyuria. 

Prooxosis. — The  projrnosis  deitends  u;reatly  ui)on  the 
stasre  of  the  disease.  \Vhen  thi'  ainyloid  deposits  in  the 
kidneys,  lunjrs,  and  other  orj^ans  are  no  lonjrer  recent, 
and  the  patient  is  much  weakened  by  the  chronic  disease, 


122 


I)Isi:asi:s  or  nii:  kidseys. 


tln'  |'i'<>u'iii>>is  is  V"'rv  iiiit'iiVDriilili' ;  iifViTtlu'lfs,-,  in  soiiu' 
(jiiili'  ailvaiiccil  ciiscs  of  s_v|iliilitir  oriu'iii  tlif  |>iitii'iit  may 

Olltil'flv    I't'CnVlT    lllllilT    S|K'citi('    tl'iMtlllcllt.        I*'v('ll     ill    old 

cast's  caiiscii  liv  siiiiimratioii,  wlicrc  tlic  discaM'il  Ipihic  dt 
(ttlit'i"  siiii|iiirativi'  cause  can  1k'  rt'innvcd,  tiic  aiiiyloid  dc- 
jMi-iits  may  lie  alisorlicil  and  the  |iatient  ivcdver. 

'I' in:  AT  mi:  NT. — 'Piie  indications  for  trcatineiit  arc  tor  tlie 
removal  of  tile  cause  ot'  tlie  disi-ase, — vi/,.,  sjieciHc  treat- 
ment ill  syphilitic  cases,  and  the  removal  of  lu'croscd  lioiie 
or  cai'lilaii'e  where  |iossihle.  'I'he  |>atielit  should  he  |ilaced 
under  the  hest  hyu:ieiiic  conditions,  with  iri'nei'al  tonic 
treatnu'iit, — iron,  (|ninine,  stimulants,  etc.  In  chronic 
Hii|>|>iiralion  of  the  limits  or  other  irreiiiediahle  disi'ase 
the  treatment  must  he  lari;ely  symiitomatic,  in  the  liopu 
of  itruloiiging  the  life  of  the  patient. 

FATTY    DKCKNKItATlON. 

Tile  kidneys  are  suhji-ct  to  fatty  dc_<reneration  when 
their  uutrilioii  is  interfered  with  hy  disease  of  the  hlood- 
vessi'ls.  or  hy  pressure  upon  the  vessels  liy  new  trrowths  or 
exudations;  in  shoi't,  anythiii<;  wlTu-h  produces  a  iiernui- 
iieiit  amemia  of  the  origan  will  he  liki'ly  to  cause  a  fatty 
metamorphosis.  (V'rtain  poisons  taken  into  the  hlood, 
and  certain  patholoifical  conditions  of  the  lihjod,  are  calla- 
ble of  brint;iii,<;  ahout  fatty  kidney. 

AmoiiiT  the  poisons  t^iviiii;  rise  to  fatty  kidney  are  phos- 
phorus, arsenic,  antimony,  and  alcohol;  amoiiii:  the  dis- 
eases causinu;  it  are  i>hthisis  pulmonalis,  scr.ilet  fever, 
small-pox,  and  puerperal  tever. 

Especially  when  the  epithelium  is  in  an  advanced  sta<re 
of  deireiieration  will  we  find  alliumen, — not,  however,  in 
such  (juantities  as  in  amyloid  dcireneration  or  tuiiulitis. 
It  is  very  probable  that  in  many  cases  of  sliii'ht  ''.Ibumi- 
nuria  in  preijnancy  or  in  tbe  acute  infectious  diseases,  or 


>'JLi 


dMl 


ATitoi'iiy  .\M>  iiyi'rirrnorm: 


1J:{ 


ri-siiltinirt'n.in  thr  a.lministratiui.  ..f  |.Mi-nn  ul.-iv  ili.iv 
is  n..  .Iropsv,  it  is  .In*'  to  .l..,irfn»Taii..i.,— tl.at  is,  a  luitritiv.. 
.list-as..  of  ill.'  r|.itl..-liMiii.  Wl.ri,  tlic  .alls..  ..f  tin-  imtn- 
tivi'  .listiirl.aiuv  is  iviii..v..l,  tiu'  .K.,irviuTati..ii,  as  a  nil.-, 


irt  s.iKii  r.'|iaii'*''l 


cii  A  i*T  i:u   X  I  X. 

ATUOIMIY    .\M»    IIYI'KUTHOI'IIV. 

Atu.iIMIV  .)f  tJK'  l<i.iii.-y  may  U-  .•oiii^mital  or  a.'.iuiml. 
Wlu-M  .•..Mir.'i.ital  it  is  liUrly  t..  1...  miilat.Tal.  uitli  .■n- 
lariri-tii.'iit  or  liyia-rtropliy  of  tlu-  .)thiT  ki.lu.-y.  A.-iuirra 
atrophv  is  tlu- "ivsult  of  a  imtiitiv.-  .listiirl.aii.f. 

lAniJuMiY.— Anything'  wlii.-li  .listiirl.s  tiu-  imlrition  of 
tho  ki.liiov  may  pPMlu.'.'  atn.i.i.y.  Sii.-li  w..ul.l  1...  tiio 
case  where  tumors  of  the  al..h.m<ii  press  u|...n  or  inv<.lvij 
the  renal  artery;  oJiiholism,  tliroml.osis.  ..r  (UIj.'V  disease 
of  the  vessi-U  sutH.-i.'iit  t..  .h-prive  the  ki.iiiey  of  its  |.r.)i.er 
nourishment  may  .'ause  its  atn-phy;  while  in  .•lin.nie 
tuhular  nepliritis  we  often  tin.l  nutritive  disturhan.-e  an.l 
oonse.iuent  shrinkaire  of  the  or<;au. 

These  tw.)  kidneys  whi.h  I  n..w  show  you  (h»  not  wei-ch 
more  than  tw..  an.l"  a  half  ..un.cs  ea.-h,  the  patii-nt  havin.ir 
(lio.l  ..f  ehroni.'  tuhular  n.-fhritis,  the  result  of  ex.-.'ssive 
use  of  aleoliol  f.)r  tw..  or  tliree  years.  I  .lesire  to  .all 
your  attention  to  the  faet  that  hoth  ki.ln.'ys  are  c'.,ual1y 
atrophie.l,  an.l  that  tlu-  atn-phy  is  at  the  expense  of  the 

cortical  i.orth.n. 

When  the  atr.iphv  is  the  result  of  pr-ssure  of  ah.lominal 

tumors  it  is  generally  unilateral. 

We  occasionally  tin.l  ohl  age  a.-ting  as  an  eti.. logical 


«k 


124 


Disr.tsh..;  fir  TiiK  i\ii>.\i:ys 


fiiftMr,  tilt'  k'uliifvs  III'  iild  |i('ii|i|c  Id'iu^'  "I'ti'ii  tjiiiti'  siiuill 
ami  |iiiitjikiiiir  in  n  imasiirc  (if  the  u'cmriil  atrnpliy  dt" 
otliir  ()ri;iiiis. 

I'ATiini.ipiiv. — In  virv  ulil  |>(n|ili'  w f  tVfi |ii(iil  1 V  HikI  tlu' 
kidiicvs  siiuill  or  atr(i|iliii'(l  witliniit  tluir  litiiit;  dlsca-^t'tl 
ntlHTwisc  tliaii  ill  lia\  iiiir  siitliicil  wiiiu'  fattv  tli-p-iicnitinii. 
Ill  (•(iiii.''iMital  cases  I  have  si'cii  inif  isiiiall  ami  oiii'  lariat' 
kiilii<_\.  iniltur  litiiiLT  tliscascd. 

Wf  liavf  alrtaily  runsiiliTcil  tin-  paflioldiry  (if  tliu 
atropliv  of  cliruiiir  tiilnihir  in'|iliritis  iiiidfr  its  iiropcr 
lit  iidiiiLT.  I>iit  it  inii^lit  \>v  wfll  to  rt'iiiark  lnii'  that  tin- 
.filial!  irraniilar  kiiliit  y  t)|'  iiiftrstitial  !it|iliritis  is  imt,  prop- 
crly  Hpiakiiitr,  mi  atrti|iliii'd  kidm-v,  iiiasimifli  as  its  rc- 
(lutlii)ii  ill  si/.f  dfptiids  licit  upon  a  pMural  atrophy  of 
thf  Di'^iii,  Itiit  upon  foiitiiiftioii  of  tilt'  luw  tilinms  tissiu'. 

Symptoms. — 'I'lnrt'  an-  no  siilijfftivt'  syniptoins  which 
would  assist  us  in  diaLrnosiiii;  this  condition  diiiiiiir  Iil<'; 
hut  i)y  careful  hinianual  cxainination  in  vt  rv  wparc  persons 
with  relaxed  ahiloininal  walls  it  is  sometitiies  possihle. 

I'ltodMisis. — If  diairiiosed,  th'  protrntisis  iniist  depentl 
lariTely  on  the  cause  of  the  atrophy.  In  chronic  tulnilar 
nephritis,  or  where  the  renal  artery  is  implicated  in  a 
catieeroiis  jxrowth,  it  is  iiad  ;  where  only  t)iie  kidney  is 
atrophied,  unless  the  din-ase  which  causes  the  atrojihy 
interferes  with  the  patient's  health,  the  proLrimsis  is  favor- 
ahle,  as  persons  can  live  very  well  with  tire  kidney. 
Till'  atrophy  of  oltl  people  is  not  likely  to  interfere  with 
their  lon<;evitv. 


FIVrKKTItOPHY. 

Ve  usually  reco<;ni/e  a  etintreiiital  and  an  acquired 
hypertrophy  «)f  the  kid  ley.  As  u  rule,  eoni;enital  hyjier- 
trophy  is  unilateral,  ami  the  other  kidney  is  atr<)i»hied  or 
ahsent. 


1 


Ti  Wilis  .i.v/)  vKii   iiiifiwrns 


125 


Tt  i^  tt  w.'ll-kiiuwn  ni.t   tliat  wli.r.'  oiu'  ki.lii»y  'h  iv- 

,„o\V.l  or  l.iTnimH  ulrul.l.ir.l  llio  olIuT  l.\  l..Tfln|.l.irMll..l 

in   many  (Won   am   l.i'   iv.o.cni/..a   I.v   Imuanual   ixanii- 
natinii. 


(MlArTKU    XX. 

TiMoii,  11!*  i\Y\A\vi\  to  til."  ki.liiivs,  "h  (.ftrn  a  ratli.T  iii- 
(li  linitf  ('Xi)n-<sioii. 

All  till-  ,-nlaru'''i>i.'nts  of  tlic  ki.ln.'V  an-  usually  I'la.'.d  ii> 
tliU  .-laViH.-ation.  TikI.t  tliis  li.a.lii.u'  w."  shall  roMsi.l.T 
n.ali.ifnant  and  non-niali-uant  j^rowths,  as  vwU  as  cysts 
anil  jiarasiti'S. 

MALKINANT    (nioWTlIS. 
('„,.,.;„„„>„.— 'X\wVK'  may  l.c  sai.l  to  .'xist  tl.n-f  lu'cnliari- 
tit's  al.oiit  can. •IT  of  tlic  kidneys,— vi/.  : 

1.  The  kidney  is  .nini.arativfly  i'Xfmpt  from  camcr. 
'1.  Wln-n  it  is  tin-  sulijcct  (.f  .an.cr  it  is  fn-cnu'iitly  met 
wi'li  in  vounu'  cl.iMrcil,  and  less  friMHuntly  at  tli.-  usual 
cancer  aye.  Wlien  cancer  is  present  in  y<.un,tr  cliildr.-n, 
the  kidnev  is  mon-  ofti'ii  atta.kcl  than  any  other  orpin. 
It  is,  however,  i-rohahle  that  nniny  of  the  so-.-alled  cancers 
of  the  kidnev  in  children  are  sarconuit<  us. 

3.  The  meilullary  variety  is  of  mos',  fre-iucnt  (u-curn-nce. 
Kt,„,,o(1Y.— We  "know  no  niori-  of  th*'  causi-  of  carci- 
n.mui  of  the  kidnev  than  we  do  of  the  cause  of  .•arcinoina 
of  other  orirans,  nor  have  we  any  satisfactory  explanation 
of  its  frequent  ooonrreiice  in  younu'  <hildren.  It  is  tan- 
to  suppose  that  heredity  i.lays  ahont  the  same  part  in  can- 
cer of  this  (U-iran  that  it  does  in  others.  It  may  he  pri- 
marv  or  «ec'omlary.     When  primary,  it  u  usually  confined 

11* 


MHBrt 


120 


/)/v/.M\A.'v  nf  rut:  i<n»\h:\s 


ti»  niif  kidiu'V.      W'Ihii  !.i'iiiiii|iirv,  liotli  itrjfaii-*  aif  likily 

fii  Ire   ill\iil\ii|,  t'Xrf|if   ulliTf    till'    lI'lHcaKl'    Irt    tln'    n'KllIt   ot' 

ilirtM't  I'Xti'iHiiiii  tVuiii  iiiiidlii  r  iiii:iiii. 

Ill  ixliilt  lite  iiimIcs  ar*'  iiiikIi  nt'tt'iicr  attarkiil  tliaii 
triiialf-.      Ill  rliildnii  Hex  |tlav>«  tin  |iart. 

I'\  nini.iHiv. — It  i>*  |ii'itliali|i'  tliat  caiirt  r  nf  ihr  ki<liitv 
«l<K'rt  lint  alwavs  uritr'niati'  in  llif  i-aiin'  .-tnnruic.  In  M>im' 
nisfrt  tli«'  niin'i'i'-i't'lls  (iiitiinalf  in  llif  tjiilliijiiini  uf  the 

tiiiiiilcs,  wliilc  sdiiif   |iatliii|i»i,'i>|-*   maintain   tliat   ll aii- 

(•fidiis  trruuili  lMLj:in-«  in  tin-  tfjlnlar  li-^iif  ainiinil  tlic 
Mal|iiirliiaii  liotliis,  Srlnofdi  r  tliinkr*  tliat  raini  r  nl'tcii 
(trii;iiiat<-'  in  lln'  tn.l'iilicjinin  nf  tlii'  IiIoimI-soscIs. 

SvMi'ii'Ms.  —  h,  i.iMiiilarv  <anr(ii)iis  i'r|iu>it  in  the  kid- 
ticy  tlif  svni|il.iiiis  arc  •^cldnni  u<||  marked  ;  in  lai-t.  \»\^\- 
tiiurteiii  I'xaminatiiin  nl'tiii  nvcaN  finirrruiis  dt'|M»its 
wlu'i't'  tlu'V  \v»rc  nut  ivcn  f<iis|i(itfd  dnriiiir  lit'f.  At 
otliiM'  tiniTH  till'  |iatit'nt  may  i'tini|ilain  <it°  pain,  and  mi  ix- 
nmiiisition  tnlarirtnii'iit  ut'  oiu'  nr  ixitli  kidneys  lie  I'iiuikI. 
Wlicrt'  liotli  kidmys  are  invdhcd.  a  diai;ni.-is  is  a  matter 
of  less  jiraetieal  ini|H(rtanee.  as  lliere  may  lie  depiisits  in 
(itlier  organs,  and  iititliiiiLC  is  tc  lie  lioped  I'.ip  rinm  treat- 
ment. 

In  jirimary  eaneer  oltlie  kidney  we  L'eiurally  have  tour 
|iroiiii)ient  syiii|»toms,  one  tir  more  nt' wliieli  arc  always  to 
lie  I'lMiiiil. — viz.,  Iienii»rrliai;«',  |iaiii,  tiimnr  or  enlariremeiit, 
and  eaiK-iToiis  eaeliexia.  Ileinorrliatre  is  present  in  al'oiit 
olie-lialt"  tlie  eases,  heiliij  si  nietinii'S  tile  Hl'st  sym|itom 
wliicli  altraets  the  attention  ot'  the  patient  or  physician. 
In  utlu-r  cases  ha'tnatnria  may  occur  at  wry  irretrnlar  in- 
tervals (luriiiiT  the  coiirsi'  of  the  disease.  When  heiiior- 
rha<re  iic<'iirs  as  a  very  early  syniptoni,  lu't'ore  the  api>eiir- 
ance  ot' any  tumor  or  cancer. uis  cachexia,  it  is  not  possihle 
to  make  a  diatrnosis,  as  the  hemorrhage  iiiitjht  he  from 
liypencmiu  or  stone. 


Tl  Mons  AM>    VKM    UHUWTUS  \'i1 

Pain  in  ih.i  iiKvav-  pr.'^.iit,  in.r  (.tt«'ii  h.v.it.  iiikI  ii.ViT 
pr.Hlur.'K  tlif  Hfvnv  iitta.-kMof  niial  .ulif  tlial  ary  a-... 
riiil.Ml  Willi  III-  pas-a-r.-  of  rnial  .'alruli.  ( ».va-i..Mallv 
^..vnv  |.ain  mav  iv»iill  iVnin  tl.r  pivsm.^  (>n.ln.H|..l..is  in 
ll.r  iiivt.r-.  Wli.'ii  sii.li  i'  III''  'iiM.,  Imiic  ^triiijTH  ..r  .Intr* 
,,|-  1,1, „)il  will  It  IuiiimI  ill  iIk'  iiiiiK'.  Tli.-  pain  Lmih  a 
nilr.  .lull  aii.l  a.liiii'.'  in  .liaia.t.r.  siliialr.i  al.niit  tli.-  Lark 
an. I  loins,  uftrn  pas^iii.tr  .lown  lln-  l»';;s  nr  inio  tin- Ma.l.l.  r, 
l.nt  it  is  s.l.loin  s.'vnv  in  tlu-  fi-stid.-,  iik  irt  tiv<|nfnllv  tlio 
i-asc  in  irravi'l. 

A  .•iin  I'lil  l.iinaniial  .•xainination  will  alwavs  .l.ti'.t  any 
r.nwi.i.Tal.l.'  tumor  Ih-Iw.tii  tli.'  L.w.r  ril>  ami  llir  iliar 
K-YK'sX.  Till'  tumor,  mil.ss  wvy  larLff.  p-m-rally  itlaiiiH 
K.mn-wliat  tin-  sliap.'  of  tli.'  ki.ln.'V.  It  is  nsnallv  lixy.I, 
an.i  .Im.s  not  move  with  llif  ad  of  i-i'spifatioii.  'I'll.' 
jrrowtli  may  involve  111.'  inf.  rior  v.'iia  <'ava  ami  i-kmIii.-.' 
,.n,irorir''m''i>t  of  tlic  ulHl.nniiial  v.-ins,  willi  <lr.>|.sy  of  tin' 
ft.t  aii.l  l.'L's. 

Oil  tilt'  ri.irlit  side  tli.'  Ii.'patif  .liK't  may  lu'  inv.ilvcl  ami 
jaiiii.li.'.'  I'.siill,  ..!•  til.-  portal  .•ir.'nlati..n  i....y  l>o  int.'r- 
f.i'..l  with,  wli.'ii,  lu-si.l.'s  .p.l.-nia  .if  tin,'  fc-ct  iUul  K'^'s, 
as.'itfs  will  Mipt'rv.'in'. 

The  caflu'xia  in  .an.'.r  of  ih.-  ki.lii.'y  is  i|nit.'  .-liarac- 
tcrisli.'.  111.'  pati.'iit  assiiminir  a  hroiiz.'.l  ratli.r  than  lli.- 
l.lan.'li.'.l  aiia'ini.'  Inn'.  My  last  pati.'iit  who  di.'.l  ..f  ivnal 
caii.'cr  ha.l  iKinorrhat;.'  as  an  »'aily  synipt.mi.  ami  siihsc- 
•  pu-ntlv  had  a  tixcl  kidm-y-shapcl  tnnior,  pain,  s.'v.-ro 
lu'a.la.'ht',  an.nvxia,  ami  vomitin.ir.  For  months  l...foro 
d.'ath  t'M'rc  was  st.'ady  .'iiiaiiatiim,  as  also  »>xtr.'iiif  irrita- 
l.ilitv  of  tin-  hla.hU'r,  with  oliirmia. 

Primary  cam-i'r  .>f  tli.'  ki.liuy  in  yomi'r  rhildr.'ii  arrows 
v.'ry  rai-i.lly.  often  pro.liu'inir  i-normous  dist.'iition  of  tlu> 
nlaiomcn.  It  in  not  uHsociati-d  with  mmh  wastin,;;  or 
attended  hv  scvero  liain.     There   may  he   Inematuria,  hut 


12S 


DISKASES  OF  THE   ICIDXEys 


this  (uriirs  mori"  t'm|ii.'iitl_v  wlu-ii  tlu'  siiliji'ct  is  an  old 
iiorsoii.  As  tin-  I'lisr  in'OLrn-sscs.  scfoiidiiry  iiodulfs  may 
l.c  tomid  in  tlu'  otluT  ki-liifv  or  in  tlic  Inn-rs,  i'lnariation 
will  ainirar,  and  tin-  )iatifnt  will  i>n'scnt  tin-  nsiial  caclicxia. 

'I'm:  AT  Mi:  NT. — Tlu'  trfatniciit  consists  in  attcnii.tinir  to 
proloiiLr  lit*'  l»y  noiirisliini'nt  and  tonics,  and  in  ,uivin,tr  re- 
lid'  tVoin  i>ain  l)y  the  use  of  opiates  on  the  one  hand  and 
nnioval  of  the  kitlney  on  the  other. 

Wliin  the  disease  is  primary  and  nnilateral  and  an  i-arly 
diau-nosis  can  he  made,  removal  of  the  kidney— nephrec- 
tomy— is  indicated.  (See  chapter  on  Surgery  of  the 
Kidne_\.) 

non-mali(;nant   oh   UENIUN   (IHOWTHS. 

Non-)nali!;mint  jrrowths  of  tlio  kidney  a-e  extremely 
rare.  We  do,  however,  oeciwionally  find  a  lihroina, 
lipoma,  anjrionia,  or  adenonni. 

These  irrowths  have  no  well-marked  clinical  character- 
istics that  woidd  enalde  \is  to  dia,u;nose  them. 

Althouirh  extremely  interesting:  to  the  patholojjist,  they 
hardly  demand  much  attention  fron»  the  clinician. 

When  a  tihronut  does  occur,  it  develops  in  small  nod- 
ules, and  jrenerally  in  the  pyramidal  jiortitMi  of  the  kid- 
m-y.  The  noduU's  do  not  often  ^^row  to  a  large  size. 
Fihronni,  like  any  other  now  growth  in  the  kidney,  may 
trive  rise  to  Inematuria. 

Liponiata,  or  fatty  growths,  have  heen  thought  to  c(mi- 
menco  in  the  fatty  cellular  tissue  outside  the  kidney, 
whence  they  invade  the  kidney,  destroying  tae  renal  tis- 
sue, protlucing  atrophy,  and  converting  the  organ  into  a 
mass  of  fat.  There  is  no  possihle  means  l)y  which  this 
condition  can  he  diagnosed  during  life. 

Adenoid  deposits  have  heen  found  in  the  kidney  ac- 
companying leucocytluvmia  and  lymphadenoma. 


(USTS  <»r  THE  A7;>.VA)'. 


1-29 


Cases  of  uTioiiiii  have  lu't'ii  n'i..)rtc(l  t'lom  tinu'  to  tiiiic 
as  small  tumors  .Uvelopfd  in  flic  cortex  (.f  the  kidiu'V. 

CYSTS  OF  TIIK  KIDNKY. 
Cysts  of  tilt'  kidney  are  divided  into  simple,  eoii,ir«'iiital, 
ovstic  dcj^eiKTution,  and  hydatid  cyHts. 
"  Ivrioi.o.iY.— SimpU'  cysts  may  he  dilatations  of  tnlmlefl 
or  Malpighian  capsules,  and  he  the  result  »-ither  ..f  oh- 
^truction  in  the  luminaof  the  tuhules  or  of  their  ohliteni- 
tioii  hv  compressioii. 

(\)n"irenital  eysts  prohahly  orii^inate  in  the  same  way. 
Virchow  ascrihes  the  conixenital  cysts  to  ohstruction  of 
the  uriniferous  tuhules  hy  inflammation  duriiiii'  f'l'tal  life. 
The  oriran  is  found  at  hirth  to  he  in  a  state  of  cystic  de- 
generation ;  in  other  words,  hein.u  a  mass  of  cysts  in  \vhi«-h 
the  proper  secreting  structure  is  lost,  and  attaininsr  such 
a  size,  at  times,  as  to  he  an  imi.ediment  to  the  hirth  of  the 

child. 

Some  pathologists  doubt  the  existeni-e  ot  cystic  do- 
generation,— that  is,  that  cysts  originate  from  enlarge- 
ment of  the  secreting  cells  of  tlie  kidney. 

The  kidney  is  not  the  subject  of  hydatid  disease  as  often 
as  the  liver  and  tin-  lungs.  'Exactly  how  the  parasite  finds 
its  way  from  the  digestive  organs  to  the  kidney  has  always 
been  a  matter  of  speculation. 

Patiiolo(}Y.— In  the  condition  of  simple  cyst,  the  kidney 
may  he  normal  in  appearance  or  irregular,  with  the  out- 
lines of  cysts  from  a  minute  size  up  to  that  of  a  walnut 
plaiidv  visible  under  the  capsule. 

In  "cutting  open  a  kidney  of  tubular  nei>hritis  a  great 
number  of  small  cVsts  may  "be  found.  It  is  in  this  patho- 
logical condition  that  we  find  the  cysts,  as  dilated  tubules 
f  r^Malpiirhian  capsules,  the  result  ..."  obstruction  of  the 
tubules  by  blood,  pus,  concretion,  or  fibrinous  exudation. 

i 


l:]0 


DisKASEx  <ti'  Tin:  KHK\i:ys. 


Ou  tlu'  c.mtnirv.  th.'  cysts  f.Min.l  in  intvrstUial  lu'i-hritis 
luv  tlu-  n-sult  ..f  ..l.litrratioi.  <>f  tlu'  tulmlcs  hy  tlu-  cuu- 
tractioii  of  till'  new  tilirnus  tissue. 

Cv.ti.-  <lr.<.-n.Tati..n  shows  an  .■..lar-muMit  of  sc.-ivtint; 
,.,.li:  „n.l  .•o..s...,U(Mt  .on.pivssion  of  tlu-  stnu-tuiv  ot  tlu- 
ki.lm-v,  .aiisin.tr  .U.,i:.',uTati..n  of  its  tissiu-s,  ivsi  inMm.ir  m 
a  ni.asuiv  the  ovarian  .yst.     (See  V\i£.  If..  I 

Hydatid  eysts  are  formed  hy  the  eiieapsuhition  and  I'V- 
liferation  ofthe  parasite  ta>nia  e.liino.'orens. 

Symptoms.— Thi'  ki.hiev  may  eontain  a  htr^o  nniiilKT 
<,f  <n.all  evsts  seattered  throu-hont  its  eortieal  iH.rtion 
1,„,1,  i„  ..l,n,„ie  tnladar  an<l  in  interstitial  nej.hntis,  and 
.nve  no  indieution  of  their  existence.  Shouhl  the  eysts 
he  verv  hirire  and  directly  nncU-r  the  .avsule,  they  nn-ht 
lu.  reco.niized  hv  [.liysical  examinati.m.  I  have  seen 
,„,,.,„Hna  uluTc"  Mwh  cysts  were  fonnd,  hut  wo  as  otten 
have  ha.n.atnria  in  chronic  tuhnhir  ov  interstitial  nq.hntis 
where  no  cysts  are  j.rcscnt. 

Hvdatid  cvsts,  usuallv  unilateral,  are  likely  to  soon  ac- 
quire so  hir-e  a  si/e  as  t..  he  easily  reco<rni/cd  hy  mspec- 
tion  or  l.hvsical  examination;  in  fact,  they  may  hll  the 
whole  side'of  the  ahdomen,  and  may  he  mistaken  on  the 
left  si.le  for  .-ystic  disease  <.f  the  si-leen  or  ovary,  and  on 
the  ri'Mit  side  for  hvdatids  of  the  liver. 

i:ai?an.t..n.ii"s  have  heen  ma.le  tor  the  removal  ot  ovarian 
t„,nurs  where  the  operaK.rs  found  they  had  to  deal  with 
hvdatids  of  the  kidnev.  When  they  arc  Mualler  they  mi.-ht 
he  mistaken  f..r  a  hy.lrone,.hr..sis.  In  any  case  as,.ini- 
ti„n  on-ht  to  cstahlish  the  dirt'erential  dia.uMiosis  hetw-een 
ovaria,rrtuid.  urine.  an<l  hydathl  Huid  containing  portion, 
of  the  hvaline  walls  of  the  dau-hter  cysts  of  the  cohino- 
..oecus.  ■  Hvdatid  cvsts  may  rupture  into  the  pelvis  ot  the 
kidney  and"  the  fluid  es.-api-  with  the  urine  m  which  it 
,au  h'e  recoirni/.cd.      The  passage  of  this  Huid  through 


ItaMMIt 


J^.m    ■  ^^..M- 


cysrs  or  riu:  /»'//).v/:i', 


i.n 


lu'i'liritirf 
xUv  roH- 

scrl-rtillir 
W  (»t'  llu' 

nlilin.ir  in 

aiitl  in'ti- 

>  nuiiiluT 
il  |ii»rtiiin 
iritis,  iiiid 
tlic  cysts 
loy  miirlit 
layt'  sei-n 
f  as  ot'ti'U 
1  nojihritis 

o  soon  ac- 
hy inspoc- 
ay  till  the 
ken  on  the 
ry,  au<l  on 

of  ovarian 
t  (h'al  with 
they  niijrht 
asi'  aspira- 
■;is  bi'tweon 
iij;  portions 
the  echino- 
ic-lvis  of  the 
ill  wliieh  it 
id  through 


Fid.  If.. 


Cyslic  det{eneriili<ai  of  kiJiiey. 


I 


1 


m 


;,-  -•  1*— r    ■ 


"1 


III 
itiiiii 


J32    •  /)/s7;  ts7>  or  riii:  lansrvs. 

,.  nrrt.r  and  uivtl.ra  is  s..uu-tinu-s  a<ro,niKinu"(l  by  much 

'p,;„,,..„s._TlK'  siinpU.  cysts  ofcMth.-r  tul.ular  or  in- 
torsti.ial  nephritis  ,.rohahly  i..t.ri;.n-  litth;.  if  at  all,  wUh 
the  t.r-nvss  of  th.-  .liscas...  I.a,-.  cyst..-  .h-yn.rat.on 
lv\.o,;i.U.t.lv  destroy  thon.nal  tissue.  In  hy.latuls  the 
;ni^.n..si;  is  certainly  unlavorahle.  The  eyst  n.ay  o,-. 
Lt.rthe  uhaon.inal  eavity  or  the  eellular  t.ssue  surn.un.l- 
hiK  the  ki.lney.  hut  in  favorahle  .-uses  the  kuhu-y  n.ay  he 
removed  an.l  the  i.atieiit  reeover. 

r,.,,,,,,,,,,.Nr.-There  is  no  nii.lieal  treatment  api-lieahlo 
to  the  evsts  of  interstitial  or  tuhnlar  nephritis. 

When,   unilateral   and   eou-enital,  the   indi.-ation   is  to 
remove  the  ki.lney.     (See  chapter  on  Sui-ery.) 

O.-easionally  hydatid  cysts  have  luvn  iuspirated,  lodme 
injected,  and  the  c£we  reported  as  cured. 


itaM 


.;*as^^ 


'd  by  inuih 

mliir  or  iii- 
at  all,  with 
I'tjciuTation 
iy(lati«ls  tlie 
t  may  ojn'M 
i-  siirroUMtl- 
lu-y  iiiiiy  l»e 

it  ap|>rK':il>le 

ication  i^  to 

•■) 

i-uted,  iotline 


HK.XAL  lAurLis,  sTost:,  sTosy  coycjarnoss.  133 


SKCTKJN    III 
DISEASES    OF    THE    PELVIS. 


(Ml  A  I'TKK    T. 

RENAL  CAU-nAVS  STONE,  STONY  CONCRETIONS-HENAI.  COl.ir 
_  NEl'llHC-l.ITIIIASIS—  I'YEMTIS  CAIX'ILOSA  —  CAU  ILI 
KEN  A  LI  A. 

[v  .•(msi.UTin-  tlu'  (lisiMisos  of  tlic  folvis  of  tho  ki.l.u.y, 
Wi'  sl.all  tako  ni.  stoiu-  as  one.  of  tlio  most  imi.ortant. 

Tlu-  term  renal  .•al.ulus  is  .^ronorally  uniU'rst.M.d  to 
nu-an  stone  in  the  pelvis  .,f  the  kidney,  hnt  there  n.ay  he 
deposits  also,  either  eon-enital  or  ae(,uired,  m  the  tuhnlos 
„r  in  the  kidney  proper.  These  tubular  .lei-osits  are  olten 
desiiiiiated  "  coneretions "  or  "  ^'ravel."  ,     ,      .     ,, 

Whether  e.meretions  in  the  tubules  or  eah'ulus  in  the 
pelvis,  these  deposits,  as  a  rule,  partake  of  the  nature  ot 
the  salts  of  the  urine,-uric  ac -ul,  the  pliosphates,  lime,  etc. 

IvriOLOUY.-The  cause  of  stone,  (■omretions,  or  grave  , 
whether  in  the  kidney  proi.er,  in  its  pelvis,  or  in  the  blad- 

der,  is  obseure.  .        ,.       ^. 

To  savthat  they  are  the  result  of  defective  digestion 
and  assiinilati...!  -ives  us  no  exact  knowled.irc  on  the  ..nb- 
ject  as  the  nature  of  the  tault  in  the  di-estion  or  assimi- 
iati<.n  which  produces  the  stone  has  never  been  satistac- 
torilv  explaim-d. 

Amonir  the  manv  theories  on  the  subject  may  be  meu- 
ti.me.l  one  which  ascribes  the  deposit  to  the  inability  ot 
the  urine  to  hold  its  salts  in  suspension. 


1 


-".  .iggimif  vr. 


l:U 


i)isi:.{si:s  OF  the  kid. sins. 


Tl.is,  limvcvcr,  is  iiuilty.  as  it  a^iirns  ii..  .-xiict  <lM'tni.Ml 
rrasni.  \nr  llu-  lUilmv  of  i1h>  ii.im'  to  I1..I-I  its  suits  in  solu- 
tion. .   .  . 

Miclvi'l  maintains  tliat  tlu'  foriMation  of  pivniMfatos  is 
not  iv(iuisiti'  for  tl.f  i.rudnction  of  a  niinarv  ralmlns, 
l.iit  tliat  it  .l.-iMuds  ni>«.i\  a  spociHc  fatanii  (.f  tli»'  urinary 
passa-jri's.  falK'il  I'V  iiim  >•  stonc-formin.u  ratarrli." 

In  tliis  .•on.litio'n  tlic  mucous  nu'ml:nuu'  is  fV.ii.|K>KtMl  to 
sr.nt.'  a  tou-h  adiicsivi-  mucus  wliich  lias  a  tctidcu-y  to 
.i,.i,l  frrmcntation,  .iurin.ir  wl.irli  tin-  ..xalati-  of  linu'.  ap- 
ocars.  lie  liolds  tliat  almost  all  stones  consist  prnnarily 
„f  oxalate  of  rune,  to  which  m.u-c  is  added  from  the  do- 
c.omi.os..d  urine.  If  the  urine  l.ec..mcs  alkaline,  he  main- 
tains, the  oxalate  of  lime  in  the  stone  is  displaced  at  hrst 
hy  uric  aci.l  and  urate  of  ammonium  and  afterward  hy 
the  phosphates,  thm  ecmverting  an  oxalic  into  a  phos- 
phatic  calculus.  ^ 

Whatever  \\\v  chenrnal  causes  arc,  there  is  no  doul)t 
that  heredity  plays  an  important  part.  There  is  in  cer- 
tain families  a  stnm.i;  hereditary  tendency  to' the  forma- 
tion of  urinary  calculi ;  in  other  words,  s(un<'  persons 
posst'ss  a  stone  diatlii-sis. 

In  this  connection  I  may  mention  that  there  seems  to 
be  an  intimate  relation  between  the  gouty  diathesis  and 
the  urinarv  calculus  diathesis.  We  not  infrequently  see 
in  the  same  family  some  members  who  are  the  subjects 
of  urinarv  calculi,  while  others  are  victims  of  gout:  and 
it  often  hapi.ens  that  persons  who  Inive  luul  attacks  ot 
renal  colic  ov  stone  in  the  bladder  in  early  life  develop 

'"  CMiinate  v-an  hardly  be  said  to  be  an  etiological  factor 
in  this  disease,  whih-  locality  has  a  very  decided  mtlu- 
enee.  It  is  found  to  bo  particularly  prevalent  in  hme 
districts,  where  the  drinking-water  contains  lime  in  ex- 


iiiM 


(  clicmiciil 
Its  ill  solii- 

•ijiitatcs  i^^ 

k-     Cilll'lllllS, 

ln'  uriiiiiry 

;i|i|)(>M'tl  to 

ciMlfiu-y  to 
it'  liiiH'  mt- 
t  |irimiirily 
oiu  tho  (ln- 
ic,  he  inain- 
ci'd  at  tirst 
fti'i-warcl  I'V 
;it()  a  phos- 

s  no  (l()ul>t 
IV  is  in  vi'i'- 
•tlK'  t\>riiia- 
iiu'    juTsons 

n'd  socnis  to 
iatlK'sis  and 
L'quontly  see 
tho  snhjofts 
f  i^oiit ;  and 
I  attacks  of 
lite  devehtp 

otj;ical  factor 

L'ciihMl  intlii- 

U'lit  in  lime 

lime  ill  ex- 


A'/;.v,i/,  (wr.rrr.r^.  wo.vk,  srn.sy  rn\rt;i:Tii>\s.    1:{.'> 

,M-ss;  for  instance,  in  the  eastern  section  of  Kndand 
urinary  calcnli  are  nindi  more  piwalenf  than  in  th.'  west- 
ern. Xorway  and  Sweden  are  notahiy  i'xempt.  not,  la.w- 
pver,  on  a<-coiint  of  tlieir  cold  climate,  for  stone  is  of 
fre.,nent  occnrrem'c  in  {••eland.  On  the  other  hand. 
India,  with  a  hot  .liniate,  ontrihwtes  a  -"""H.v  'l""'»''  "' 

eases.  . 

.h/c— That  renal  stone  is  more  tre(,u,'nt  m  youni;  adult.^ 
than  in  the  ai^'ed  seems  to  he  the  prevailin-  idea  of  m..st 
writers.      My  own    experience,   liowever,   i-oints    m   the 


Fio.  17. 


''""I'  In  n 


,  i\»^ 


\V^ 


..i.V^^'' 


.,v\ 


SlOIlf  III  tM'lvlK. 


Stone  in  iiroliT. 


NVphro-lithlasls. 


opposite  direction.     T  have  collected  a  lar-e  nnmher  o1 
rcMial  eahaili,  all  of  which  are  from  eases  oceiirnn-  in  my 
own  practice,  ami  not  one  of  them  is  from  a  i-erson  under 


the  age  of  twenty. 


'rA 


c  «r 


186 


i)ish:Af<i-:s  nf  Tin:  i\in.\i:is. 


Tln'  iiiiii  ri'tioiis  simkcii  of  as  <»c(  iirriiii;  "m  tlif  tiiliiilcn, 
liowfvor,  jiiH-  iu»  <l«tiil»t  (ifti'iuT  tiiiuul  ill  iliililrcii  tliiiii  in 
((itlcr  i.trsiiiis.  Miilfs  iirc  iiiiicli  iiKirc  lrc(|uciitly  siil»i<'(t 
to  tliis  foiiilitimi  tliiiii  t'l'iiuilts. 

Fiir.  J"  irivi's  a  Itianlilnl  iiliistratioii  ol"  tin-  iiuidi-  of 
foniiatioii  of  ri'iial  caiciili  in  tlif  pelvis  ami  tlii'  sulistaiice 
of  til.'  i<i(lm'y.  Tilt'  lartri'st  stone  eoiiiiiletely  tills  the 
pelvis,  while  tliefe  are  three  other  stoiu's  in  the  hodv  of 
the  kiilni'V.  The  stone  in  the  ni'i-ter  must  have  heroine 
(letai'hed  from  till'  pelvic  stoiu-  an<l  foiiml  its  way  into  the 
ureter,  wiiere  it  ln'came  imjiaeted,  or  il  may  have  made 
its  way  into  the  ureter  from  the  pelvis  hofore  the  forma- 
tion ol'  the  liirire  pelvic  stone. 

The  stones  in  the  hody  wer*-,  of  course,  primarily  de- 
posits in  the  tuhules. 

The  patient,  a  native  of  France,  thirty-nine  years  of 
a.<re,  consulted  Dr.  L.  Hazet,  of  this  city,  in  Xovemlu'r, 
iS'.tl,  complainiiiir  of  severe  couirh,  great  «"jiiaciation,  and 
irritahle  hla  Ider.  lie  ha<l  contracted  a  urethritis  in  his 
tweiity-st'cond  year,  and  had  since  had  several  attacks. 

His  family  history  was  good.  In  1888  he  was  treated 
in  I'aris  hy  I'rof.  (Juyon  lor  cystitis. 

He  came  to  (\ilifornia  in  18S!»,  in  fair  health.  When 
admitted  to  the  Polyclinic  Ward  of  the  City  and  County 
Hospital  in  Deiemhcr,  1891,  he  was  much  emaciated, 
ve;y  ieehle,  had  a  severe  cough,  and  complained  of  pain 
over  the  jiuhes  radiating  to  the  right  luml.ar  region,  with 
freipient  micturition  of  mnco-puruleiit  urine.  There  was 
a  cavitv  in  the  apex  of  the  right  lung,  and  hepatization 
in  the  c  base.  Hectic  fever  was  present;  tuhercle- 
ha<-illi  ahounded  in  the  sputa. 

To  relieve  the  irrital.ility  of  the  bladder  Dr.  Uazet 
performed  cystotomy.  The  iiatient  died  fourteen  days 
afterward,  of  pulmonary  complications.     He  had  never 


tiilmli'n, 
tliiiM  ill 

V    Sllltjt'l't 

lllixli'   ol" 

ultstaiicc 

tills   the 

hotlv  ul' 

Ikh-uiiu' 

•  into  tho 

VC     lllil<U( 

10  foniiii- 
larily  ile- 
yi'iirs  of 

DVflnlllT, 

tidii,  and 
tis  in  liis 

ttiicks. 
IS  tri'iitt'd 

.  WUi'u 
(I  County 
iniK'iiitt'd, 
1  of  |>ain 
jion,  with 
'luTo  was 
latization 
tiil)iTcle- 

)i-.  r>azot 
tern  days 
lad   iK'Vi'i' 


A'.'  ,.\i.  r.i/.rrr.rs,  smxh:.  sruM'  fo\fHh:ri>).\s.    l:l7 

('oiiii>laiiiid  of  pain  in  tlif  rcirioii  of  tiic  kidin-y.  N'ot- 
witlistaiidinjr  tlif  liirj^*-  stone  inipactt-d  in  the  iiritcr,  llnrt- 
was  no  liistorv  of  renal  eolie. 

The  irrilallilify  of  the  liladder  and  the  iiiuco-|.iiriileiit 
urine  wi-re  attiiituted  to  tiilienular  cystitis,  which  the 
post  mortem  *'xaiiiinatioii  showccl  to  lie  ahseiit. 

I'A'riiOLOdicAi.  Anatomy. — Three  varietii-s  only  of  cal- 
culus are  common, — nanudy,  uric  acid  ai  d  its  coiiipoiiiids, 
oxalate  of  lime,  and  tin'  mixed  phosphates. 

Calculi  of  large  nize  are  seldtim  of  the  same  coiiii)()siti<in 
throuiihoiit,  lii'int;  usually  arran,<red  in  conei-ntrie  layers 
altout  a  nucleus,  which  may  he  of  uric  aciil.  oxalate  of 
lime,  hlood-clots,  or  forei^Mi  liodies,  hut  is  very  rarely  one 
of  till-  phosphates. 

T/vV  arl'l  calculi  are  the  most  eommon.     They  an  of 
reddish  color,  and  <,'enerally  smooth,  hut  may  lie  tuhcnii- 

lated. 

OxnJiile  nf  limr  calculi    an-  of  a    dark-hrown   or  .trray 

color,  and  usually  tuherculated,  whence  the  nam. lul- 

herry  calculi  "  often  applied  to  them.  ()c"asioiially  they 
are  "small  and  smooth,  constitutint;  the  so-called  "  hemp- 
seed  calculi." 

('alcidi  of  the  )ii!jril  phrtsphntes  are  ('(imposed  of  jihos- 
phate  of  lime  and  triple  phosiihate  of  ammonium  and 
mairnesium.  The  phosphates  often  make  up  the  external 
lavers  of  calculi  of  various  composition,  hut  seldom  con- 
stitute the  nucleus  of  a  calculus. 

Calculi  have  sometimes  heeti  found  comjiosed  of  car- 
honate  of  lime,  xanthin,  cystin,  and  urostealith. 

Sv.Mi'To.Ms.— We  shall  take  up  the  symptoms  under  two 
]ieads, — namely,  renal  calculus  and  renal  colic. 

The  first  includes  the  symptoms  that  result  from  the 
presence  of  stone  in  tho  pelvis  of  the  kidney  or  from 
tuhular  concretions;  tho  latter,  the  symptoms  attending 

J2» 


V\H 


ni.sHASKs  nr  TiiK  KinsF.ys. 


tllf    l.iHriiliTf    nl'    tin-    siMll.'    t'n.Ill    tlir    |Hlvi^<    ul'   ill.'    lo.lll.'V 
tliiuiit;li  llif  iirctiT  to  III"  l.lii'ltl.T. 

Ciii.Mili  s..iiicliiiM's  piiMlii.T  M.I  paiti.  Iiul.  ii<  ii  nil.',  .■illuT 
tiiliiliir  ...IK  TfliniM  ..r  llif  pri'Sfii.*-  of  sloii.'  in  tli.-  imIvih 
will  lie  ali.ii.l.'.l  l>v  III..!.'  ••!•  l.'ss  |.iiiii,  of  imIiiII,  iKliin,!,' 
(•liaia.'ttT.  .'iilit  r  .•.•ii^tniil  <.r  iiit.'riiiitltiil,  itir.irniviitfil  l.v 
111. .vfiii. 'Ills  ..f  111.'  ImhIv,  and  s..iii.  liiii.'  t'..ll..'.viii.Lr  lli<' 
.•..uiM'  ..t'  th.'  ur.'i.r  !<•  tlif  .trroin  ..r  iIk'  t.'sli.l.'.  Il  may 
....mimi,'  lur  ni..nllis  an. I  l.c  a.'.'..iti|.ani.'.l  l.y  t.ndi'rn.'ss 
on  pii's^ur.'.  In  piTliap-  I. all'  lli.'  .as.'s  lli.r.'  i^  lia-nia- 
turia.  wlii.'li  is  siil.if.'l  l.»  n"  nil.'  a-^  !.>  lli.'  t'r.'.iu.n.'.y  of 
its    o.'.'un.'ii.'.'.     S..m.'lini.'s    tli.T.-  will    1..'    Imt    a   .T^'lit 

1„. nhiiLr.':  at  ..iIkt  times  lli.'  alia. 'ks  will  ln'  i|uit.'  piT- 

sisl.nt,  an.l  pi'iliaps  a.'.'..mi>ani.'.l  l«v  i-Vflitis;  wliiK'  in 
still  otluT  .'as.-s  111.'  st.iiH'  may  1..-  iv'taiiu.l  ai-panntly  lor 
11  ./r.'at  Icn.irtli  ofiim.'  in  ih.'  ju'lvis  witli..nt  i.roauciiijf  in- 
tlamiiiati.)!). 

In  infants,  .l.'|).isifs  of  urates  or  |>lios].liat.'s  are  often 
,;,„„.l  i„  ,h,.  .liaiMTs.  Tlii'se  prohaMy  have  tl.eir  ..ri.irin 
i„  111,,  nil.iiles  an.l  lli.'ir  passajre  tlir.Mi,i;li  tli.'  nr.'ters 
causes  e.tnsiili'ialile  pain. 

The  lirst  in.li.ati..n  ..f  r.'iial  .'oli.-  is  ireiierally  a  sudden 
oiislau,i;lil  ."f  I'ain  as  the  stone  eiit.rs  ih.'  ureter.^  Tin.* 
seM..ni  ... •ems  while  th.'  |u-rson  is  walUinir  or  sittiiiu:  np- 
r^dii,  l.nt  lakes  plae.'  when  he  is  stoopin-r,  heiidin,-r  over, 
or  lyin.u'  down,  as  th.'  lM..|y  is  the-i  in  a  more  favoruhle 
positi.>n  for  the  stoii.'  t.)  eiit.r  the  ur.'ter. 

The  sntferiiiLr  is  sonu'tiines  so  severe  as  to  cause  faint- 
in.;:,  the  patient  fallinir  into  a  e<.llapsed  .'on.lili.ni,  soon, 
however,  rallyiniT  to  riali/.e  the  intensity  of  his  pain. 

At  lirst  the  pain  is  so  <rreat  as  t.>  make  it  dirti.ult  .>f 
exaet  loeation,  the  patient  in  his  a«r.>ny  referrin.ir  it  to  the 


nr.SM.   rttl.ir 


ITJ 


If   k'wliH'^ 

lllc,  citlliT 

till'  I'tlvin 
ill,  iK'liiii,!; 
•avatt'il  liy 
iwiii.!,'  fll"' 
It  iiiav 

ilMtil'riH'KK 

is  liiiMim- 

(lUillfV  <>t 

t  a  I'.'lit 
(|uitf  pfi'- 
;  whili'  ill 
iirtiitly  tor 
uliiciiii;  in- 

I  art'  ot'tt'U 
luir  orii^iii 
\\v   urt'ttTs 


V  a  suddt'ii 
i.trr.     Till* 

sittiiiu:  ii|)- 
idiiii;  oviT, 

V  tiivombU' 

cause  faiiit- 
itimi,  soon, 
s  |iain. 
ilitHrult  of 
iiiT  it  to  the 


,.|itiiv  al.ildinni:  ami  it  is  ,.iil.\  l.v  tlir  do^rst  .|iirstioiiiiii: 
niiil  alt.iitiuii  oil  til.'  part  --I'  iIm'  pliysiriaii  that  it  will  !..• 
JMcati'ii  ill  oiii-  or  thf  otlit  r  ki'lmy. 

As  thf  stone  passfs  down  tin-  ureter  the  pain  heemnes 
l.-ss  ^r.-neral,  euiitiniiiLr  itH»'lf  prill,  ipally  to  the  eoiirse  of  the 
ureter,  lieiii,!,'  aniioyiiij;  in  the  leLrioii  of  the  Madder,  and 
lev.'ivin  the  jrroiii  and  often  ill  iIk-  tesliele;  and  when  the 
eidenlns  arrives  at  the  hase  of  the  hladch'r  it  fiviiueiitly 
products  iiitenso  pain  in  the  head  of  tin-  [.cnis,  with 
tcncsniUM. 

The  extreiiie  atToiiy  which  the  patient  sntfers  <d'len 
makes  it  impo^sihle  for  him  to  r.inain  more  than  a  few 
iiK.nients  in  any  tixed  position,  lie  rolls  over  th.'  Led, 
and  even  on  the  floor,  and  will  oct-asionally  lind  i.  Ihf  l.y 
^I'ttiiiir  on  his  knees  and  pn'ssintr  one  or  liotli  hands  into 
the  alMloniell  over  the  atfected  ureter. 

The  pains  are  almost  always  accompanied  hy  severe 
vomitin-r  and  retchinjr,  which  add  ir''«'iitly  to  the  distress 
ot'  the  patient.  Some  complain  also  of  intense  hoiuhiclu'. 
There  is  usually  ,<ricat  mental  depression,  tt.ircther  with 
pallor.  c(dd  feet  and  hands,  and  profuse  cold  sweatii^tr. 

These  attacks  may  l>e  of  a  few  Ijours"  duration,  or  may 
continue  for  (hiys.  In  one  of  mv  earlii-st  cases  the  attack 
lasted  nearly  ten  days,  the  patient  hardy  survivimr  the 
passajfo  of  the  stoiu'. 

The  stone  may  hecoine  impacted,  convertintr  the  eas'e 
into  one  of  h\dronephrosis,  or  it  may  uh-erate  lhrou<,'h 
the  ureter,  death  ensuin<r  in  this  event  from  the  entrance 
of  the  retained  urine  into  the  ahdominal  <avity.  Durinir 
attacks  of  renal  colic  I  have  sometimes  known  the  pain 
to  intermit,  irivinir  the  patient  immunity  for  a  few  min- 
utes or  oven  half  an  liour:  in  sueli  eases  the  cessation  of 
pain  is  prohahly  the  result  of  the  escape  of  the  urine  past 
the  stone. 


140 


/)/s7;.isK>  or  Tin:  A//'A>;r\ 


DlKKKIlKNTIM.    1)|  \'1N'>SI,-.  —  Ijrillll    iiilic  tMlirllf  IH>ttii1t<' 

iiii'tiik.M  t'ur.iitiTiilv'iii.«'\'-i|"i.l"iliiil'-*.ii>  >•"■  "'iiiiiifM'i- 
III. lit  ul"  111.'  iittu.k  vvli.ii  ill  Im.iIi  fii^t-H  iIm'  piiiii  H.i'iiM  to 
lie  ilistriliiit.il  t'|iiiillv  <»v.r  ili.'  iilMluin.ii. 

(Ml  ill.'  ru'lit  t*'u\i'  it  niiiilit  I"-  |MM^il»l."  t.i  iiii'^lnk.'  tin- 
liiiiii  ..t'  rt'iiiil  ••'•li.'  I"..r  tliiit  .if  i.mI1-^I<'Ii«'.  '""  "'"  "  '''^^  '"""'^ 
til.'  |inin  of  till'  loriii.T  pas-..-;  .l..uii  tli.'  iir.l.T,  wliil.-  llint 
ol"iriilI->toin-  ir«  loiitiiH'd  t.>  tlif  .■|.i'.M'iiium  ami  ili.'  r.'L'ioii 
,,|'  ilic  iiv.T.  Uoih  iiiiiy  lu'  iu'f(»m|iiiui<'<l  liv  i-Xfcs^iv*- 
voinitiuir,  rclrliiiiu'.  .-wcalini:.  pallor,  niiil  cxIiaiHtioii. 
hat.T,  in  irall-^>'>".'.  Jaiimlir.'  .siiiuTVi'iu's.  'I'll.-  |iassa.!;f 
tlii'.Miu'li  til.'  uri'ttT  of  .lol^  of  lilooil,  liydatiils,  or  niii.'o- 
■piiruli'iit  mall,  r  iiia.v  pr.xliio'  s.'v.r.'  pain.  Iml  in  notl.in.u 
like  what  is  I'xpirii'iKH'd  in  any  oiilinary  alla'k  of  niial 
c.lii'.  I  oiK't'  liail  a  patient  in  wli.piii  a  lar-;.'  .•on.r.'tiou 
wiH  inipa.l.'.l  in  tin-  npp.T  part  of  tli.-  (l.'s.fn»rmiCc<.lon, 
^'iviiiir  risi'  to  irrcat  pain,  and  siiiinlatiiii;  closely  K-ft  renal 
roli.'.  Soon,  however,  thi-  howelrt  iH-ennii'  p-eatly  dis- 
leiid.'.l,  and   the  preseii.e  of  ..lislrn.tioii  was  evi.l.'nt. 

I'lioiiNDsis. — As  a  rnle,  tlu'  pro;inosis  is  favoraMe.  The 
piilient,  in  u  few  days  after  the  piissaj;e  of  the  stone,  will 
liave  entirely  reeov.red. 

Oeea-ionallv  a  sl.me  heeotnes  ini|taete<l.  and  death  may 
result  from  nleeratioii  or  rnptnre  of  the  pelvis  <»f  ihe  ki<l- 
nev;  hydronephrosis  or  pyi'lilis  may  f.dlow,  and  result  in 
destruetioii  of  the  kiilney. 

Tkeatv  The  treatment  of  renal  eoiK-retions  and 

stone  ie  ,is  of  the  kiiliiey  will  of  necessity  he  moro 

or  I  .  .niatic,  and  usually  .'onsists  in  allayiiii;  pain, 

if  .ruhle,  with  attempts  to  dissolve  the  coneri'tions 

or  si.Mic  hy  solvents.  The  success  of  solvent  medicinert 
will  depend  larijely  on  tlu'  character  of  tin-  stone.  The 
most  saULruine  therapeutist  would  hardly  expect  to  dis- 
solve un  oxalate  of  lime  calculus.     Many,  however,  have 


NKS.il'  ifu.n'. 


Ill 


„-...rt...l  tl.rir  uLiliiv  t..  .li^M.lvc,  l.-.tl,  ii.  ll..'  1"  Isi-  "f  '1'" 
ki.lM.v  i.n.l  ill  tl..'  l.la.l.lrr,  K».m.--  loniir.l  ..I   i.nilr.  mi..I 

,„•  ivn.r.li.M  mU'UiM  lor  .  |..i.iiiiir  tl..-  ml..-  ot    fl..ir 

....iwivtiMM.  ;n..l   1 iMv.lis.nlvin-  .al.nli,  \{nUrrt..  ^^Un 

|„M  .MV.M  M...IV  i.ll.nti..ii  I..  tl.iH  s.il.'rt  timii  i»TlnM.s  .m.v 
oth.T  ■mtl...iitv.  think,  umst    liiiililv  mI"  tlic  ritn.t..  .....I 

„,.,al.-  of  l...tu^HUiM.     Tli.'sr  ..ilts  sl.u.iM  1h"  triv.n  m  trnni 

o„..-l,all'  1. .•  <1>».-I.i>i   'l-'S  ^v..ll  .liliil.'.l   will,   wal..-, 

.,v..iy  tl.iv.'  or  Wuu-  Lours.  Tli.ir  iulMiiirMtn.ti..ii  may  Ik- 
,,,„„i„„,.l  t;,r  vv.vks,  au.l  .wi.  in  s..n..-  .us.-s  lor  n.ontlis, 
without  tl.'tnin.-nt  |,.  tl..' .li,u"'>*liv«' ori^aiH. 

WIn-ii  it  l»-.-..ni.s  i-vi.hiit  that  th.-iv  i-*  a  st.m.-  in  tin' 
iH-lvis  oflh.-  ki.ln.-v,  ami  it.-«  |.n-s»-n.v  is  nnl..-aial.h-  .-itlii-r 
from  pain  ..r  in  .•onsn,n.-ii.v  of  tin-  i.ro.ln.-t..m  ..1  disc-asi-, 
„n,l  solvi-nt  rc-im-.lit-s  huv.-  fiuU-.l,  tlu-  ki.liioy  must  Ik-  ro- 
,nov.-.l  l.y  siir-i.al  i.n.cv.Uuv.     (S.-.-  rhapt.r  on  Suru^'ry 

of  thf  Kitlm-y.) 

[l,„,,l  ('M:—\n  .-a.s.-s  cf  (-olhips.>,  wlu-n-  tin-   pnlsi-  is 

oxtivim-lv  woak,  tin-  .•.mnti'iiau.-*-  i'ul.-,  uiul  tia-  t.-»t  and 

l.aials  rohl,  tin-  in(li.ati..ns  aiv  to  apply  hi-at,  ami  ,|:iv.. 

stimulants    with    opiat.-s    until     na.ti..n    is    .stahhsla-.l. 

Whm-  tlu-rc  is  no  .ollaps.-  lla-  in.li.ation  \^  to  adimnist.-r 

„,,iatos  in  sulK.i.-nt  .,uantity  t..  luakr  tl..-  pam  ,.n.!ural.lo 

durinu' tht' I'i'^-"'".-'' "•  •''^' '^*""'"-  ,     , 

V„n  will  tiu<l  that  many  writ.-rs  n-omnn-nd  hot  Laths 
in  a.lditi.m  io  ..piat.-s.  with  tin-  vi»-w  of  n-laxin-  tin-  ur.-t.-r  ; 
hut  hot  haths  ov  the  appliration  of  h.-at  sulH.-n-nt  to  k.-.p 
up  a  constant  and  oxcoHsivo  Hwc-atin,!/,  whilo  tlu-y  may 
jrivc  some  n-licf,  will  rc-turd  rathor  than  fa<-ilitatr  tla-  pass- 

airo  of  tin-  stone. 
'  'flu-  .-ahulus  m-vcr  passes  thron-h  the  uivter  hy  reason 
of  its  relaxati....,  hut  is  foree.l  throu-h  l.y  the  pressure  ..t 
the  urine  l.ehind  it.     So  long  us  there  is  oxcesHive  a.-tion 


1 12  disi:asks  of  tui:  hin.\/:y.s. 

lit"  till'  skill  tlic  iirtioii  lit'  tilt'  kiiliicys  will  lit-  iiisiilHcit'iit 
to  loHH'.  with  iiMV  (Iciircc  ot'  riipiditv,  the  jiiissiin'i'  ot'  tlio 
stoiii'.  'I'liis  is  fsjii'ciiillv  till-  cast'  as  tin-  i-xtrt'iiit'  VDinitiiiif 
nt'tfii  iiiakfs  it  iiii|iossililt'  to  rt'taiii  tliiiils  in  tlif  stipinacli. 

M_v  iiwii  iiit'tliiMl  t)t'  trtatiiiij:  niial  colif  is  to  ix'wv  o|iiat('s, 
iTfiicrallv  iiioi'iiliiiic  iiv|ii>(K'riiiifally,  iiiiK'ss  tiifi-c  is  unifli 
follajist',  ill  w'  icli  fast'  1  use  tin-  tiiiftiira  ojiii.  1  in>ist 
ii|Miii  the  |>a.  ..t's  (Iriiikiiii^  t'lvt'lv  of  water,  farhoni/tii  or 
iiiiiii'ial,  weak  tea,  t>r  whatever  Maud  li(|iii(l  he  |prt'l'ers.  in 
the  htijie  that  some  will  lu'  retaiiieti. 

Wht'ii  |iossiltlt',  I  ki'eji  the  patient  on  his  tei-t,  walking' 
ahtnit  the  room,  to  irive  him  the  heiietit  of  the  actitm  t>t' 
ijravitv,  whit'll  is  eoiisiderahle  where  the  stone  is  near  the 
hiadder  and  tiu'  ureti'r  is  iilletl  with  urine. 

Where  the  voniitiiii;  is  so  I'Xeessi'.e  that  it  seems  iui- 
jiossihle  tor  tluitls  to  lie  retainetl  Itinir  enoiiixh  to  he  ah- 
Horhi'd,  I  have  thought  that  it  niiirht  he  well  to  use  larue 
I'liemata  of  'varni  water,  thus  su[ijil\iii<;  urine  to  t'oree 
aloni-  the  stt>iu'.  I  have  not  yet  tri"d  this  ]ilaii.  litiw- 
over. 

IV'cause  of  the  vtimitiiitr,  it  is  usually  iieeessarv  to  ad- 
minister opiates  either  h\|ioderniieally  or  pi^r  reetiim.  I 
seldt)ni  use  less  than  one-half  uraiii  of  morithine  for  the 
first  injiftion,  followed  every  hour  or  two  hy  oue-eiijhth 
or  oue-i|iiarter  of  a  i^raiii.  as  the  easi'  may  re(|uiri'. 

Laudanum  may  Ik-  injeeted  intt>  the  reetiim  in  tlraehni 
doses  every  lumr  or  two  until  the  jiain  is  hearahle.  An 
exeelleiit  su|)|tositorv,  when  that  methotl  of  nietlicatioii  is 
resorted  to.  is  tuie  eonsistiiiij  t)f  morjihine  one-half  ijraiii, 
hyoseyainiis  five  ti'rains,  ami  a  sufHcii'ut  ([Uinitity  of  oil  of 
theohroma. 

When  there  is  an  itliosynerasy  airainst  mor|iliine  or 
o|tium.  the  next  hest  remetly  is  ehloroform  or  ether  atl- 
ministered  liy  inhalation. 


dMi 


irv  to  ad- 
■ctiiiu.  I 
U'  tof  tlu' 
lU'-t'i'i'litli 

II  (li'acliiii 
il.U'.  An 
licatidii  is 
alt'  <rra'm, 
of  oil  of 

r]iliiin'  or 
otluT  ad- 


riioi'ini.A.Mx  or  /.•k.v.iA  cM.cri.i. 


148 


Should   thr  atlark  .oMtini.r   for  srvcTal   davs,  as  s..i.u'- 
tl„H.s  hapiions.  th..  patimfs  stivii^th  ..n.st  1..  n.a.ntauu.d 
l,v  ivrtal   iioiinshninit.      In  .hh-  of  ni.v  tirst  casrs,  al.va.l.v 
,u..|itiono.l  as  lasliii^  t.n  davs.  tin-  patiml  l.an■l^  siirviy..! 
,1,..  nassa-n- of  tin-  stoiir,  altlmn-li  hr  n-nvrd   iionnsh- 
,„.,„,  l.vtliol.ouvlsn-nlarly:  and  it  n.av  l..  uvtl  to  say 
l...n.  tllat  thr  .Inratimi  of  thr  attack  was  ,.rol.aMy  ..wn.t; 
to  tho  tivutnuMit  nitlHT  than  to  tin-  si/,  of  tin-  stony.        I.o 
c.onsultinLC  l-hysi.ians  in    llu'   .aso   wo.v   .urn   ..t    al..l.ty 
,„,1  ,.x,K-ri-nc*..      I  was  a  younjrstor  then,  and  .-arru'd  <  nt 
,1h.  instnu-tions  of  my  .I.Kts.  whi.-h  w.iv  to  ,ir.vo  o,,.at.s 
rathor  spariuirlv,  and  .onstant  haths  as  h..t  as  th*'  iiatn-nt 
,„„ld  otnlnr.  ilu'tn.     His  voinitin- was  v.ry  d-.st.vssin-, 
and,  tiuT.'  iK'iL.i,^  l»it  littU.  fluid  s..,Totod  hv  t'.K-  kidiu'ys, 
tho  i.assaixo  of  tho  stono  was  dolayod. 

I'ltOPllYLArTIC  TUKATMKNT   (>F    UENAL   CALcrLI. 
A  pationt  who  has  oxporionoi-d  a  sovoiv  attaok  ..f  ivnal 
,..,r,o  is  anxious  to  osoapo  a  roourron.'o  of  the  torrihlo  pan., 
and  ho  naturally  asks,  '>  What  oan   I  do  to  provont  suoh 
sutlorintr  in  tho  futuirr' 

WliiU'  niuoh  oan  oftou  bo  don*,  to  ward  ott  subsc(iuont 
attaoks,  phvsioians  wl...  l.avo  had  any  oonsidoral.lo  oxpo- 
rionoo  with"  theso  oasos  ar.'  ohli.iro.l  to  aoknow1od-o  thoir 
frequent  failure  to  provont  such  attaoks. 

In  nianv  oasos  tlu'ro  sooms  to  ho  a  stron.ir  stono-inakni.s; 
,li,thosis,"and  when  wo  have  done  all  that  lies  in  ..nr  powor, 
scoonded  hv  the  oonseientious  ofi'orts  ..f  tho  patient,  the 
formation  .if  renal  oalouli  still  oontim.es.  Su<-h  taduros, 
however,  must  not  dis,-<.ura,iro  us  and  provont  us  Iron, 
hohlin-  out   In.pos  t..  the  pationt  that  ho  nniy  stdl  get 

roliof  from  his  malady.  ^  ,       1 1 

We  have  overv  roas<.n  to  holie  e  that  tlie  primary  trouble 
is  with  the  digo^tivo  orga.is.     The  diet  should  reeeivo  our 


mmM 


144 


DISHASHS   OF   Till-:   hIDSKiS. 


I 


lirst  iittt'iitioii.     Wt'  imist  iiiii>ri'ss  upon  our  imticiit  tla' 
iiii|inrli(iici'  (>(■  cxtTcMsiiiu:  irrciit  ciirt'  in  ri'Hiinl  Id  liis  food. 

Till'  <|uaiitit_v  of  footl  slioiild  Iff  iiiodorati- and  ri'ixulatod 
willi  iifdciuo  to  till'  lialdls  ot"  tlif  individual,  wlu'tluT 
active  of  sftK'iitary. 

If  tlif  ]iatirnt  is  liviiij^  a  vtTv  activi-  lifi',  or  from  sonio 
individual  |H'i-uliarit\-  i\'(|nii'i's  more  than  an  ordinary 
amount  of  food,  let  iiini  eat  four  or  live  time's  a  day, 
rather  than  ovtM'load  his  stomacii  hy  takinjr  two  or  tiiree 
too  hearty  meals. 

The  unality  of  the  food  is  as  important  as  the  (piantity, 
if  not  I'Vt'ii  more  so.  Xourishinir  ami  eusily-diirested  fo;>d 
is  what  w*'  siionld  advise;  anil  in  doing  so  we  must  re- 
memlier  that  doctors  often  nnike  mistakes  in  being  too 
arltitrary  with  other  peoiile's  stomadis.  Most  digestive 
organs  liave  tiieir  pecidiaritit's.  As  a  rnle,  meat  should 
not  he  too  freely  indnlged  in,  hnt  shonhl  bo  jtartaken  of 
sparingly  twieo  a  (hiy  at  most.  The  meat  sh<»idd  he  varitMl, 
the  patient  being  warned  against  too  irecpieiit  indiilgiMieo 
in  beef. 

Fisli  is  nsmtlly  allowed,  but  I  have  doubts  as  to  its  pro- 
priety where  the  stones  are  phospliatie. 

The  manner  of  eating  food,  no  K-ss  tlnm  tlie  quantity 
and  the  (piality,  is  of  great  importance.  When  the  stonuieli 
digi'sts  food  Well,  the  patient  shotdd  eat  slowly;  when  it 
does  not,  he  sliould  eat  very  slowly. 

Let  the  non-nitrogenous  foods  prevail  in  the  stone- 
making  and  gouty  diatheses,  limiting  the  vegetaldes  which 
are  richest  in  phosphates  when  the  ealcidi  passed  are  phos- 
pliatie, and  avoiding  those  whieli  abound  in  oxalates  when 
oxalate  of  lime  prt'dominates  in  the  ealeuli. 

Kice  is  an  exiidlent  article  of  diet  in  most  of  these  eases, 
und  a  taste  for  it  should  he  cultivated. 

i'ork,  veal,  hashes,  highly-sesusoned  gravies  and  dress- 


rtMi 


i-RnrHVLASix  or  uksm.  cm-ci  i.i. 


14.") 


iit'u'iit  the 
I  liis  t'otid. 
regulated 
,   wlietlier 

Voiii  some 

(ii'diiiary 

les  n   (lav, 

(»  of  three 

'  (Hiaiititv, 
■ested  t'o.xl 
'  must  re- 
bel II  t^  too 
:  dii^estive 
•at  shouhl 
irtakeii  of 
he  varied, 
n(hil,u;enco 

to  its  pro- 

e  quantity 
lestotuaeli 
\- ;   when  it 

the  stone- 
])]i.':i  wliieh 
il  are  i>hos- 
ihites  wlieii 

hese  cases, 

and  dress- 


iiiiXS,  witli  rieli  (U'sserts,  must  he  ahsohltelv  es.hewed. 
The  preparation  of  tlie  foo.l  is  uu  important  factor.  Meats 
shouhl  he  broiled  or  n.aste.l,  rather  than  stewed,  fried,  or 
baked.  The  very  In'st  food  can  l)e  rendered  indi,i;estil)le 
in  its  preparation. 

Ne.xt  in  importance  to  re.v'ulation  of  the  too.l  m  tlie 
prevention  .)f  stone  are  the  .pnintity  and  variety  of  Ihpiids. 
Individual  physicians  ditU'r  alu.ut  the  variety,  m  re-ard 
to  ..timulants,  tor  instance.  T.ut  there  can  he  no  .luestion 
that  a  pcrs.)n  with  a  .stone-makin.ir  diathesis  sliould  take 
m(ue  than  the  ordinary  amount  of  tiuid. 

In  individual  cases  mineral  waters  are  no  <h.uht  hene- 
iicial.  Sprin-s  containin.i,^  different  salts  ar.-  hi.irhly  recom- 
mended hv  various  authorities  and  apparently  in  the  same 
elass  ..f  .-ases.  Patients,  too,  are  often  h.ud  in  their  praises 
of  certain  sprins^s  to  which  they  happen  to  have  been  rec- 
(mimendod.  I  str.>mrly  suspect,  however,  that  the  beneht 
derived  from  a  sojourn  at  Carlsbad,  f<.r  instance,  is  often 
due  more  to  what  the  patient  d\d  not  take  while  there 
than  to  the  therapeutic  etfeet  of  the  mineral  waters. 

I  have  great  eoiitidenee  in  distille<l  water  or  carbonized 
distille.1  water  taken  freely:  nevertheless  patients  will 
often  take  mineral  water  with  more  relish  and  in  greater 
cn.antitv  than  they  will  distilled  water.  I  <uice  had  pre- 
pared ti.r  a  patient  of  mine,  in  whom  everything  e  se  had 
tailed  to  prevent  tlie  producth.n  of  st..ne,  distilled  water 
eliarged  with  oxvi;en  gas,  without  benefit,  however.  In 
Bom^  cases  wher;  what  is  really  ncede.l  is  rest,  with  less 
food  and  less  whiskev,  we  may  often  prevail  on  the  patients 
to  trv  the  springs  when  every  other  means  to  secure  rest 
and  the  most  stringent  restriction  in  diet  have  proved  of 

""Besi'des  the  srreat  number  of  the  springs  of  Oalifornia 
with  every  variety  of  water  at  every  temperature,  we  have 
ok  18 


14«i 


DISEASES  or  THE  KIDXEiS. 


tlu'  ii(l\  lint  aire  nviT  tlii'  iiiiiuTal  spniitjs  of  all  other  conn- 
trii's.  ill  tTuiiatr:  we  liavi'  springs  at  tin-  i(h)1  soa-sidc.  in 
tlu'  hot  valkys,  ami  at  all  altitudes.  W'l'  are  thus  oHereil 
as  irreat  a  variety  in  teni|>eratiire  and  eliinute  iis  in  the 
eoniposition  of  the  iniiuTal  waters. 

1  do  not  In-lieve  that  there  is  one  per  eent.  of  these  cases 
that  the  use  of  toltaeco  will  not  injure;  and  the  same  may 
be  said  of  the  use  of  ale<)iM)lie  liiiuors. 

A  healthy  aetitui  of  the  skin  should  be  insured  by  reg. 
ular  bathinir.  txenise,  and  the  wearing  of  wurm  tlaimcl 
underclothing  summer  and  winter. 

As  to  tlu'  administration  of  medicines,  let  me  say  that 
there  is  no  specific  that  will  prevent  the  formation  of  renal 
calculi.  We  are  fori'ibly  reminded  by  this  Htone  diathesis 
that  the  scii'iice  of  medicine  is  not  an  e.xact  scien«-e.  I'ntil 
we  posst'ss  a  more  exact  knowledgi'  of  the  etiology  of  renal 
calculi  we  must  grope  iibout  in  the  dark  for  u  remedy  to 
prevent  their  formation. 

Medicines  are  of  use  in  keeping  the  bowels  soluble  and 
in  maintaining  the  secretions  and  digestion  in  as  good  con- 
dition as  possible:  Henry's  magin'sia  and  rhubarb  answer 
well  for  this  purpose.  I  am  in  the  habit  of  prescribing  a. 
mineral  acid  in  combination  with  a  vegetable  toni<-  wher 
the  tendency  is  to  oxalate-of-lime  deposit,  and  the  iodide, 
citrate,  or  acetate  of  potassium  with  calutnba  or  quassia 
when  the  phosi)hates  or  urates  prevail,  adding  wine  of 
colchicum  in  gouty  cases;  citrate  of  litliia  often  Keem.«  to 
be  ctHi-acious.  It  is  very  ditHcult  to  di'tcrmine  the  bene- 
ficial results  of  any  special  com-se  of  tri-atrnt'nt,  for  the 
reason  that  in  some  cases  of  renal  cahulus  without  trt'at- 
nu'iit  there  is  no  recurrence  of  the  trouble,  while  in  other 
csises  there  is  a  constiuit  repetition  despite  any  method  of 
treatment  employed. 

There  is  a  possibility  that  the  new  remedy  piperazin, 


I'YEI.ITIS. 


147 


)ther  conn- 
si'ii-sidc,  ill 
lius  iifli'ii'd 
!  lus  in  tlie 

tlu'Sl'   CilSOS 

'  saiiH'  may 

red  I)y  roj^- 
inii  tlatiiiol 

no  say  that 
i<tn  of  renal 
»e  diathesis 
iieo.  Tntil 
\iry  of  renal 
I  remedy  to 

solnlile  and 

s  yood  ((in- 

)arl)  answer 

^eseribinj;  n 

tonic  wher 

the  iodide, 

or  qnassia 

n\r  wine  of 

L'n  seein.'  to 

e  the  heiie- 

.'iit,  for  the 

itliont  tri'ut- 

lile  in  other 

method  of 

)•  piperazin, 


whi.li  is  now  hein.s  tried  for  tlie  .ondilion  .ailed  hv  Mr 
William  Uoherts  nrastosis,  will  prove  elHia.ious  m  pre- 
veiitiiii;  the  formation  of  st(.ne  composed  of  urates. 


ClIATTEU    II. 

PYELITIS. 

I'YF.MTls  is  an  inflammation  of  the  mneous  meml.rane 
lininij  the  pelvis  of  the  kitlney. 

KTM)Lo«iV.— This  is  rarely  a  prinuiry  disease,  that  is,  a 
disease  urisin-  from  takin-  cold,  from  injury,  or  from  some 
HO-ealled  idiopathic  cause. 

Secondarily,  however,  it  fre.iuently  *.ccurs  lus  an  accom- 
paniment or 'a  se.iuel  of  some  one  of  the  acute  inlectioUK 
lli^eases,— particularly  scarlet  feyer,  diphtheria,  .-holera, 
and  typhoid  fever.  I  have  had  si'veral  cases  of  pv<-litiB 
aocompanvim;  or  followin-  la  -rippe.  Occasionally  the 
pelvis  is  si.id  to  be  the  seat  of  a  true  diphtheritic  exn<.a- 

tion.  .    „ 

Renal  calculi  are  the  most  constant  causes  of  intlamma- 
tion  in  the  pelvis,  while  pyelitis  is  found  in  every  case-  ot 
tuhen'ular    kidney,    as    W(>11    as   in    most    cases   ot    renal 

abscess.  ,        .    ^, 

A. rain,  we  constantly  meet  with     -condary  inflammation 
of  the  pelvis  extending'  from  lon-standin-  sti'icture  <.. 
the  nn'thra  with  .-vstitis,  and  from  inflammations  ot  other 
abdominal  orjrans.     Thus  we  see  that  a-e,  se.x,  and  chmate 
have  little  to  do,  directly,  with  thi'  etiolo.try  ot  pyelitis. 

pATiioLoav.— I    have  spok.-n    in   previous  chapters   of 
pyelitis  produced  by  urinary  calculus,  as  well  ius  ot  the 
Tivelitis  of  tuberculosis. 
'  When  the  pyelitis  follows  or  accompanies  one  ot  ttie 


._J 


148 


Disr.isEs  or  Till-:  KinsEvs. 


1       i 


ju-iit*'  inli't'tious  disfiiscs,  or  is  tlic  nsult  of  cxtciisioii  t'n»in 
tilt'  lihuldcr.  \v«'  i-xjurt  tlic  iiitliiiiiiiiation  wliiU-  it  is  coii- 
tiiH'd  to  till-  iiiiuous  iiiiMiltraiif  to  i!;'^*'  ^  'i"'"'  «'iitarrli!il 
coiKlitioii  tlic  patlioloiry  «»f  whirh  ditH-rs  in  no  way  troin 
tliat  of  iiitlaiimiation  of  tin-  imicoiis  Mn.'iiil»raiH'  in  any 
otluT  or^an. 

SYMnoMs.— \V»'  liavi'  discuss.d  tlif  synii»tonis  of  stoni' 
in  the  pflvis;  tlit-  pain,  <f.'.,  hrini--  tiu'  n-snlt  of  the  stcmu 
rather  than  of  inHaniniation.  Catarrhal  intlannnations 
si'comhiry  to  tho  lu-ute  inf«'ctio<is  dismasts  or  to  cystitis  art; 
not  likely  to  bo  ushered  i;i  by  a  distinct  chill,  thouirh  the 
jtatient  may  experience  chilly  st'iisations,  Tluri-  will  not 
he  nnich  fever  while  the  intlannuation  is  confined  to  tho 
luucons  miMnhrane. 

We  nsually  find  teriderness  oviT  the  rocion  of  the 
kidney,  soreness  and  lameness  njion  movements  of  the 
hody,'and  perhaps  dnll  achinjr  pain  following'  tlie  eonrse 
of  tile  ureter  and  occasionally  felt  in  the  testicle  or  bladder. 
Micturition  is  frecpient,  but  not  urtrent,  and  the  urine  is 
very  turbid  from  the  i)resence  of  mucus.  The  microscope 
may  show  pus-cells,  an  occasional  blood-corpuscle,  and 
possibly  the  e|>ithelium  charai-teristic  of  the  jielvis  of  the 
kidney.  When  there  is  pus  there  will,  of  course,  be  u 
slijfht  trace  of  albumen. 

Prooxosts.— The  proijnosis  must  be  di'termined  entirely 
bv  the  cause  of  the  pyelitis  and  the  condition  of  the 
patient.  Tt  is  seldom  that  jtyelitis  adds  much  to  the 
gravity  of  the  ease,  whether  it  be  strii'ture  of  tlu'  urethra 
and  cystitis,  or  one  of  the  acute  infectious  diseases.  The 
pyelitis,  however,  may  involve  the  kidney,  in  which  event 
the  projinosis  will  be  serious. 

TuKATMKNT.— The  indication  for  treatment,  as  a  rule, 
is  rather  to  remove  the  cause  than  to  treat  the  disease. 
This  is   particularly  the   ease   in   stricture,  cystitis,^  and 


IMmMU  ' 


ditt 


ryn.\F.riir{<t^i'< 


149 


tension  from 
L'  it  is  con- 
■iK'  I'atiirrliiil 
no  way  tVoin 
)ranr  in  any 

onis  ot"  stoni' 
of  the  stom; 
itlaniniations 
(»  cystitis  art! 
1,  tliouirli  iIh' 
'luiH-  will  not 
intint'd  to  tiie 

['Ci<^ii  of  the 
nu'nts  of  the* 
1^  the  course 
tie  or  hhulder. 
the  urine  is 
le  microseope 
or|iusele,  and 
'  pelvis  of  the 


nined  entirely 
dition  of  the 
much  to  the 
if  tlu'  urethra 
liseases.  The 
u  which  event 


,    ,  ...,,,,,,1;      \or  does  the  catarrhal  intlannnation  f.d- 
;::  1:1        ;euU.in.VHious  diseases  call  t;...ive,pd- 

I     •   •„.  ....  t    ouiet    li-'ht  nourishing  diet,  perhaps 

:;;:;;,.::;  mIx; ';'':« n..L.  ^..M-i„.  ,w 

,:;L-, ■■■I.lori,;,.  or  iron  an,,  .plri.  •     ..J.n-  ■-  •; 

-;i;S  I'l:;  l:;-:r;' ,;x;'',,:ri^w,:i 

antemie  is  the  follow iiiir: 

U   Sulpliur.  jirH'cip., 
Fciri  <iirl>., 
(Jlycorini.  fu'i  5^8; 
Alp'"'  '"1  .^iv-— ^1- 
8i^r._A  te.i<i.-onful  ev.-ry  two  to  four  hours. 

Cod-liver  oil  i^'  very  henefioial,  espeeially  in  weak 
aelicate  ehildret*  convalescing  fro.n  acute  udect.ous  d.s- 
cases. 


CIIAPTETl   TIT. 

PV0-NEPnR0SIs(NEPHKO-PYOSIS-I'YELO-NEI.nKOSIS). 

Tub  tern>  pyo-nephrosis  designates   dilatath.n  of  the 

nelvis  of  the  kidney  with  pus.  . 

•^  T  ,  »  v.-Th,;.on,r,tio..  is  lial.lc  to  aris.  ,luru,^  any 
of  « '"n,,.nra,ivo  i„flan>n„v.u.n»  of  the  kLlnoy  or  ot  the 
mucous  membrane  of  the  i)elvis. 

The  pathology  must  ditter  according  to  the  cause.    The 

'  13» 


^■Ai 


160 


DisK.isr:s  OF  riih:  KiDsr.ys 


IK-Ivis  will   1...  .Iis(..„.|..,|  will,   |M,s  uh,.,u.vc.r  i(s  i-sriipc.  is 
pri'Viiilcd  l»v  (tltstnicti.iii  in  ilic  nii-ttT. 

SvMiTuMs.—Tlu.   sviii|.t..riis  w,.   haw    alica.lv  .IctaiU.l 
uiidrr  the  li.a.ls  ..r  the  viiiioiis  .imscs  ,,f  til,,  .lisi.asv. 

The  .■l.iira.t..nsii,-  ,lia-Mu>tic  Icaturv  in  this  .•oiwlilioi, 

IS  Ihi.   p.vmia,  |.r..vi.|...l  th,.  urctor  Ik-  |.cTvi.,iM.     Whrn 

iH'th   l<i.|ii..vs  aiv  ii.v..|vnl,  tl...  pus  ii,   the  mi.u.  is  .•,.„- 

Hti.i.t.      Whri,  ..Illy  u),..  k-i.liu.v  is  <lisi.as(..l,  tho  urin,-  may 

1)«' V..I.I..I    li„i„    the   healthy  kidury  an.!  W  pcrCMtly  th'.. 

th.m  |.Ms  t;.r  .lays,  (lu.  pus  that  aciiiimlatrs  in  th".-  .li.s. 

I'lis.'.l  ki.hu-y  os.apiiiu  intiTiiiittciitly  int..  tin-  l.la.l.l.r. 

_   Tho  iiriii,.  s...-ivfnl  issoiiL'timcs  vcfvsinall   in  aiiminit, 

jiist  oii...i,-h  to  .liiw  tlu'  pus  thn..ii;h  ihr  dis.aso.l  nivt.T 

on.'..  ..!•  twi.v  a  wook.     Sh..Ml.l  tl...  rnvt..,-  Ih..(..,u.  ,..mi- 

pK'U'Iy  .»l.stni.t...l  th."  py.)-m.plM-..sis   i„iirhf   i;,rin  a  ....ii- 

Hi.l.'i-al.l..  liiiiKM-,  it)   uhi.h   case   its  .lia^'uosis   \v..ul.l    ho 

l)ost  mad.,  hy  aspication. 

As  a  nik.,  ill  pyuria  then,  is  no  irmit  ditH.-nltv  in 
makinir  tli.'  (litll'iviitial  diairnosis  iK.twfi.n  pus  fn.m"  the 
ki.lm.y  an.l  pus  n-..iii  th.'  hla.I.l..|-.  Th..  pain  aii.l  l..n.l..r. 
tii'ss  ,.v..r  th..  iviiidii  ..f  tlu'  l.la.l.l..!-,  with  tVe.im.nt  an.l 
pamliil  mi  .tuntion,  ..n  fh.-  ..nc  han.l,  an.l  th..  pain  an.l 
t'nlari;,.m..nt  of  th.'  ki.ln.'y  ..n  the  ..tlu-r  hand,  will  ir,.„. 
orally  he  siifH.ienf  t..  ..iiahle  us  to  make  a  .liairiiosis.  '^ 
TliKATMKNT.— The  treatment  is  essentially  sur<,n.'al. 


OirAPTEH    IV. 

lIYDnO-XEPIinosiS    (HYDUOI-.S    RENALIS— HVDUO-NEI'IIKON). 

IIvniD-NEPiiKosis,  or  an  ueeumulation  of  urine  in  the 
polvis  of  the  kidney,  is  the  result  of  obstruction  of  tho 
ureter,  and  is  generally  unilateral. 


iJjM 


■■JrttiititaiiiiyMliMi 


riM 


^ 


iiyniio.\h:i'iinosis. 


i:.l 


I'ly  <KtaiU<l 
lisoaso. 
Is  •'oiiditioM 
•lift.  When 
riiif  is  cdii- 
.'  iiriiif  II lay 
'l-rcitly  free 
ill  the  tlis- 
lila*l(l(  r. 

ill    Mlllnllllt, 

asud  nrt'tvp 
'••oiiii'  cdm- 
•rill  a  con- 

i    Wolllil     IiU 

lifKciilty  ill 
IS  from  tlio 
111(1  tciidor- 
'qiu'iit  am] 
'  pain  and 
I,  will  iTc-ii- 
iiosis. 
finical. 


JEPIIHOX). 

ine  ill  tlio 
ion  of  tho 


Ktini.odY. — Olistnictioii  of  tlif  iii'ctcr  fi-om  lui.v  .iuisr 
wliilf  iIh'  kidiii'V  \r*  ill  a  comlition  to  scri'ilc  iiriiif  will 
produce  dilatation  of  tlie  pelvis,  or  li_vdro-ne|ii  osis.  Im- 
pii.ted  stom-  and  strietiire  of  the  ureter  the  result  of  in- 
llaiiimation  are  fretiueiil  eauses.  Strietiire  of  the  iirethrii, 
or  irrowtlis  in  t\u'  Madder  olistrnetinj;  the  ureteral  open- 
imr-'.  will  t,'ivo  rise  to  a  hilatorai  hydro-m'|tlirosis.  Inllam- 
matioiis  in  the  jielvis  prodiieimc  eontraetioii  ami  olditera- 
lion  of  tlu'  ureter,  or  eiineer  in  tiie  altdoniinal  cavity,  may 
involve  tin"  ureter;  ami  sometimes  lariro  alMlomiiial  tumors 
press  upon  and  olistruet  if.  In  other  words,  the  olistnic- 
tion  may  1k'  in  tin-  <aiial  of  the  ureter,  may  ho  caused  l»y 
disease  of  its  walls,  or  may  hf  the  result  of  pressure 
oxerteil  extt'rnaily  to  it,  of  trrowths  at  tho  hase  of  tho 
liladdor,  of  hypertrophy  of  the  prostate,  or  even  of 
phimosis. 

l*A'ril(ii,o(iv. — Whatever  tho  causi'  of  tho  olistruction.  the 
aoeumulation  of  urine  in  the  pi'lvis  distends  it  to  a  ucreater 
or  U'ss  extent,  and  |U'esses  upon  the  papilla*,  eausinu;  their 
llattenins;  and  iii<lnration,  and  atrophy  of  the  kidney 
tissue.  Tho  ealieos  are  o!»literati'il.  ami  notliiiiLr  may  Ite  let't 
of  the  kidney  hut  a  cortical  shell.  This  internal  pressure 
«oon  stops  the  seoretion  of  urine,  and  honeo  prevont.s  any 
inoroasc  in  tho  size  of  the  tumor.  Sonn-  patholoj^ists  are 
of  the  opinion  that  after  llio  Hoerotion  of  urine  eoasis 
tlio  tumor  iiicroasi's  slowly  in  si.-'.e  from  soerotion  l>y  tho 
mucous  inemhrano. 

Sy.mi'To.ms. — The  general  history  of  the  aymptoms  is 
that  of  disease  of  the  hladder,  alMlominal  tumors,  or  im- 
paotion  of  a  renal  caliulus,  which  <-auses  tho  ohstriic- 
tion,  and  the  tlnetnatiii<;  tumor  of  liy(lro-noi»hrosis  is  the 
j)atlio_ifnonionie  symptom. 

I)lA(iXosi.-.— Tlie  diti'erential  diagnosis  is  determined  hy 
aspiration. 


■  I  ■^■l.'JW"*'-"*  ?'■'■' 


U2 


nisH.isHs  or  Tin:  KinxKis. 


li 


I'uoiiNosrs. — TIk'   |iri)jrii(isis   i-t  trt'iiirallv  Hrrioiis,  Ix.tli 
fViMu  the  lint  fil'  the  ilisiiitcirmf ioii  lit'  ilic  kiiliHV,  and  mu 

ai'i'Uimt  of"  till'  (•||l|<c  IM'oiIlhiliir  tile  <(»lnlil'nui. 

'riti:\iMi;Nr.  —  Uniiiivc  tin;  (aiisf  wluro  iio^^^ililc     (St'u 
C'lia]it('i'  oil  Siirgt'iT.) 


err  APT  KR  v. 


I'KKINi:niKITIS. 


I'lnuNKiMiurris  is  an  iiillaiiiiiiatinu  of  tlu'  rdliilar  tissue 
and  adiposi'  capsiiK'  suiToinidiMi;  the  kidney. 

Iviiui.otiV. — It  may  he  caused  liy  iiijurii's,  sueh  as  falls, 
hlows.  Wounds,  ete.,  Iiiit  is  usually  llie  i-esult  of  su|i|iura- 
tive  iiitlaiuniatioii  of  tlie  kiiliuy  or  its  [ulvis,  or  ut'  pelvic 
Htones  wliiili  have  caused  uleeiation  or  ]ii'rfoialion. 

Tuhereular  kidney  is  ofteu  aee(un|ianied  hy  |)erine|thri- 
tis,  and  intlatuniation  may  s|ireail  from  other  ortrans  to 
the  adipose  capsule  (»f  the  kiiliiey,  as  sometimes  happi'iis 
in  perityphlitis  or  lunihar  aliscess. 

Symptoms. — This  conditiou  is  usually  ushen'd  iu  hy  a 
chill  or  recurrent  chills,  followed  hy  rise  of  •■■mpt'ratui'e, 
with  pain,  swellinii',  and  tt'iidcriiess  over  the  n  iiioii  of  the 
kiilney.     Any  motion  of  the  hody  aLri^ravates  the  pain. 

There  is  likely  to  he  fre(|uent  micturition;  hut  the  con- 
dition of  the  urine  (K'pends  upon  the  state  of'  the  kidiiev 
rather  than  ujion  the  perinephritis. 

Sujipuration  will  soon  take  place,  and  often  an  ahsccss 
can  lie  distinctly  felt  and  easily  diatrnosed. 

At  times,  howi'vcr,  tin-  pus  escapes  a](»ni;  the  jtsoas 
muscle  and  prcsi-nts  itself  undi'r  I'oupart's  lipiment.  It 
may  find  its  way  into  the  pelvis  of  the  kiihiey  and  escape 


itaai 


rinrmis 


i:i;J 


crioiH,  liMtli 

liicv,  uikI  Mil 


lliiliir  tissiu' 

iK'li  as  lalls. 
tit'  sii|i|iiira- 
<•!•  of  pflvic 
atiiiii. 
pi'tiiii'iiliri- 

I'    nriTiillS    to 

US  lia|i|ii'iis 

rill  in  hy  a 
"iiilitTatiiri', 
li'iitii  (if  ilio 
tlic  |iain. 
Mit  the  ('()ii> 
till-  kidney 

t  an  a1)soi'Srt 

r   the   psoas 

^anient,     ft 

and  escape 


with  tlif  mint',  and  it  lias  onasinnally  Imtii  known  to  pif- 
t'oiatf  tlif  diaphiaLrin  and  fscapi-  tliroiiudi  tlic  Innu's  or 
opiii  into  the  liowt'ls  or  the  alxjoininal  easily. 

I'ltiniMtsis. — The  prot^nosis  is  serious  nnle>s  the  di-ea-M' 
is  the  result  of  injury.  The  very  tiiet  that  it  is  so  often 
secondary  to  suppuration  ot'  the  kidney  niak«s  the  proi;- 
no>is  unfavoraldc. 

Titi; mmi;n T. — The  indications  for  treatnient  depend  en- 
tirely upon  the  cause.  In  cases  of  injury,  cuppinu-  or 
leechinL;,  followed  l>y  hot  or  cohl  appli<ations,  may  he 
t'oiind  iiecessarv.  The  pain  may  necessitate  «»piafes,  and 
the  li'Vi'r  antipyretics.  As  soon  as  suppuration  is  appar- 
«'nt,  nephrotomy  is  indi<'ated  ;  aii<l  when  the  perinephritis 
is  prcifded  hy  suppurative  nephritis,  nephrcctoiiiy  hecoincH 
not  only  justifialdi'  hut  even  imperative.  (See  chapter  on 
Sur!;ical  Kidm^y.)  Tlu'  striitest  diet  must  he  eiiioincd, 
especially  in  injuries  involvin<;  the  kidiu'y. 


('II A  pTKit  vr. 


t  iii:ti:iis. 


UuKTKniTis  is  prohahly  never  primary,  hut  tlu'  result  <d" 
iniIammati(Ui  spreadiiiiC  from  the  hladihr,  frmii  tlu'  pelvis 
of  the  kidney,  or  fnuii  the  ahd(uninal  origans,  or  of  the 
passajje  of  renal  calculi.  There  are  no  symptoms,  suhjec- 
tivi'  or  objective,  hy  which  \\v  can  dia<rnose  a  special  in- 
Hammation  of  the  un-ters. 

They  are  prohahly  always  more  or  less  involved  in  the 
ahove-named  conditions. 

OhsU-iirlinn  of  the  Ureters, — One  of  the  most  common 
causes  of  obstruction  of  the  ureters  is  the  impaction  of  a 


1 


IM 


msH.isF.s  Of  Tin:  i\Ut.\h:ys. 


1 1 


Htttiif  ill  its  iiiis-iii^c  Iriiiii  tlic  inUi-*  III  ilic  l<iiliii\  ;  or  tlu' 
nlt;.rnittitiii  iiiiiv  I"'  raii:*fil  •  \  u  -tii<tiiif  of  tlic  iii«  tif  the 

ri'Klllt   ol'   illthllllllliltioM    |i|oi|l|r.i|    liV   tlic    |.;lssil>:r  of  il  cal- 

iMiliiH.  Ill  tiilifrtiilosis  of  tlif  kiiliiiv  of  of  tlif  liliuliltr 
til*'  wall- of  tlif  iirt't»Tr<  an-  tliitktinil  am'  irnufiilar. -ohh- 
tiiiirs  (•aii>iiiLr  ttiii|ionirv  olistrmtion.  Nfw  i;ro\vtlis  in  llir 
lilaiMi  r  iiiMV  oli>lru<t  the  oiific.'  of  tlic  iirct'Ts,  ami  tumors 
ill  llif  alMloiiu'ii  or  pi'lvis  caiisi-  oli^trmtioii  from  iin>?*m'i', 
while  caiKcr  may  iiivailf  the  iin-tfr  ami  closr  it.  'I'lu- 
uri'ti  TH  ait'  o(ia->ioiiail_v  acfiilciitally  ciicloscil  in  liiratiin-rt 
iliiriii<;  livstfrciloiiiy  ami  o|M'ratioiis  for  ovarian  or  ollur 
pi'lvi.'  tiiiiiors.  Till'  s_viii|ttoiiirt  rt'siiltiiii;  from  oli^trmtioii 
of  till-  |iassa)X<'  of  iiriiif  would  he  pain  from  distiiitioii  of 
till'  tiilii',  ami  liytlro-mplirosis,  or.  in  sonic  casis,  rii|itiiri' 
of  tlu'   luvtor  ami  I'scapi'  of  uriiu'   inl«i   tln'  alMloiuinal 

cavity. 

I)il,if<i/i'on  can  rt'sult  only  from  olistrmtioii.  'Plif  un-tcrs 
uri'  soiiiftiiiu's  (•iiormoU'ly  dilatt  il  ami  tortuous. 

l\ri'in-iitli)ii. — Pfrfoiatioii  is  most  likely  to  lie  the  result 
of  eaiieeroiis  in\ olveiiieiit  or  ot'  nleeratioii  from  im|iaeteil 
stone.  Oeeasiolially  the  ureter  is  aeeitlelitally  opemMl 
(liirini:  operations.  In  anycuse  the  urine  eseajies  into  the 
alxlomiiial  cavity  or  the  eellular  tissiu',  jirtMliieiiig  serioiw 
ri'sults,  if  not  death. 

Jl'/l-ir/m/iliif  ,niil  Ali'»i>li;/. — In  tuluTenlar  disease  of  the 
kidney  we  find  the  ureter  j^reatly  eiilarijed  and  thickened, 
which  condition,  of  course,  is  not  a  true  hypertrophy.  It 
is  doulitful  whether  we  ever  meet  with  a  true  hypertrophy 
<if  the  ureters;  thouirh  it  is  hari'ly  possilile  that  the  <-on- 
(litioii  niiirht  occur  in  diahetes  or  partial  olistruction. 

The  ureters  ai'i'  often  atrophii'd,  and  sometimes  com- 
pletely ohiiterateil,  throULth  disea-c. 

Milfitnmitiiins. — Occasionally  in  tin-  dissectinjf-room  or 
ut  post-niortfUis  malfornuitions  of  the  ureters  arc  r.x.'t  with. 


Imv :  tir  tlic 
ic  nitt(  r  till- 
>llf«'  nt'  u  mi- 
tilt'  liliiiMtr 
i;iiliir.  -Hiiir- 

(iWtllS  ill  ihr 

,  :iiiil  liiiinirr* 
III!  |iri'>suri', 
i»-c  it.  Till' 
ill  liiTiitiiri's 
riaii  or  otliiT 
I  (ilistnictiuii 
listiiitioii  ut" 
;isi's,  rii|)tiiri' 
I'  iiliiliiiiiiiiiil 

'I'lif  urcttTx 
us. 

1m'  till-  nsiilt 
mil  iiii|iii('t*'il 
tiillv  oikiumI 
ai't-'H  into  the 
luiiig  f^iTimirt 

lisciisi'  ot'  till' 
1(1  tliickfiii'd, 
iTtropliy.  It 
liy|K'rtr()|tliy 
that  till-  I'oii- 
nictioii. 
U'tiliU'S   rolii- 

tiiij;-rt>(ini  or 
arc  iiM't  with. 


sruuir  ..  Tin:rnth:sr  <>r  rm:  lansrys       \■^:^ 

'I'll.  V  hasv  hr.u  lomi.l.  our  or  Loth.  imiKTvi-nis  at  hiith. 
(),.,.  ki.lii.-v  i...i.v  haw  two  urrt.-fs,  or  th.r..  ma.v  h.  two 
,V„M,  o.H.  ki.ln.'V  whi.h  miit..  iM.fori.  ....t.r....;  i  m'  Ma-hhr. 
Th.-.v  an-  ..f  no  |.rarti.al  im|H.rlanrc',  i-xivpl  wh.n  uupi'f- 
vioii-,  ami  in  alMloininal  »*iirj.'i'i\v. 


in 


CJIAPTKU     VII. 

81  IKM.'M.   TUKATMKNT    ol'   illK    KILNKYS. 

T.iK  operations  for  tin-  sin-i.i.l  tr.alnnnt  of  lli.'  Unhu-vs 
.,yl.f  .l.si-natr.l  as  follows:  aspiration,  nrpliiorrhapliv, 
nephrotomy,  nrphio-lithotu,„y,  ami  n.phiv.tomy. 

ASIMItATloN 

Aspiration  is  tvsort.-l  to  in  .asis  of  si.iipl.'  or  hy.lathl 
cyst,,  or  of  hy.lro-nc.phrosis.  ("uros  hayo  hoen  .fh-tiil, 
i,\  tlu'se  .US.USI.S,  l.y  a.-i.irati..n  alon.,  or  in  .oiipnution 
^vithio.^.n..inil•.■tions.  WIhiv  animation  fails,nii.hrotoniy 
i.  iiMially  ivs.'.rti'.l  t...  Sliouhl  this  proy*.  in.thTtnal  tin- 
,i„^,,  „„n,al  M.rans  still  ivinains  to  ,H,-nani.ly,  ni-phiv.- 
\.  a  ni.'aiis  of  .liairnosis  or  to  prociin-  ti'iiiporary 


toniy. 


n.ih.t;  wi.  u^.  aspiration  .n  .'Usls  of  al.s.vss,  pyo-n..,.hro.,s, 
„r  tulu.,vular  khlm-y.  It  is  .-ortainly  of  ^Mvat  n,iportan.-o 
as  a  nu.tho.1  of  .lia^'nosis,  ...lahlinir  us  to  .l.thtvnt.atc. 
'>.twi-i-,i  hy.lro-ni.pl.--osis,  pyo-imphrosts,  ami  sinipli.  or 
hy,l.  till  .'vsts.  Till-  small  i-ysts  of  .•hron.r  tnl-ular  or 
int.rtul.ular  m.pl'n'''^  ">-*'  ""'^  ^"  '"'  '"M-initiU.  Inta.t,  as 
,v..  hayi"  s..i.n,  it  is  impossil.lr  to  aia.rnos.  tlm.r  ex.ston.e. 
Mnnni.  OK  Asi'iK.vnoN.-lt  is  almost  supiTtlmms  to 
nav  that  tho  skin  wluiv  tin-  pnnrf.iv  is  to  la-  nia.K-,  ami 
tho  nt-L-illc  to  he  use.1,  must  ho  ahsolutely  usi-ptic. 


■I 


ff  1 


1 


h 


i.-.t; 


i>isi:.ts/:s  or  riii:  kidskvs 


:i 


1  |iri'li  r  ;i  irocur  lu'cillc  iiiid  the  liottli'  or  Allen  iis|iir;it<)r 
('X«'('iit   tor  (liiitrnostic  or  fX|(l<iriitorv  |iiir|ioscs.     In  iiitro- 

•  lllrini;  tlic  llccdlc  oili'  must  he  ciircl'lll  to  kft'|i  outside  of 
the  pctitotifUIu  ;  otluTwise  tlic  iliti'stilies  luiiv  he  iujuri'd, 
or  when  tlie  iieeclle  is  witlidrMWii  the  eyst  nuiy  dniiii  into 
the  ahdoiuinid  ciivitv.  We  must  reniendur  th;it  the  left 
kidney  is  a  little  liii;her  than  the  riti'ht,  and  that  tho 
neeille  should  he  introduced  lower  on  the  riifht  sidi-  to 
avoid  the  liver.  \o  very  iiw-M  harm,  however,  would  ho 
likely  to  ri'sult  from  jiiereinir  the  lower  marijin  (d'  the 
liver.  I  fre([uently  aspirate  the  liver  for  hypenemia,  with 
very  siitistiU'tory  results.  In  numy  eases  of  cysts,  pyo- 
ni'phrosis,  or  ahseess  there  is  a  jirominent  soft  tluetuatint^ 
point  which  readily  indicates  where  it  is  hest  to  introduce 
tho  noodU".  M(U'ris  advist's  enti-rini;  the  needle  just 
anterior  to  the  last  intercostal  space  for  the  left  kidney, 
hut  lower  and  farther  hack  for  the  ri<;ht  kidney. 

'*  If  there  he  no  indication  for  operatini^  olsewln're,  the 
l)est  s]iot  to  select  wlu-n  the  tumor  is  of  the  ri<;ht  kidney 
is  one  half-way  hetween  the  last  rib  and  the  crest  of  the 
ilium,  hetwei'U  two  inches  and  two  inches  and  a  lialf 
behind  the  anterior  superior  spine  of  the  ilium.  This 
spot  is  on  a  level  with  the  front  of  the  bodies  of  the 
bnnbar  vertebne,  and  a  needle  here  ])asse(l  horizontally 
inwards  will  be  alto<;t'ther  in  front  of  the  normal  kidney, 
and  will  either  transfix  or  pass  in  front  of  the  ascendintj 
ecdon  when  in  its  usual  place.  It  may,  however,  with 
safety  be  conjectured  that  in  any  ease  of  hydro-ne|»hrosis 
of  tho  right  side  requiring  to  be  tapped,  if  tho  troi-ar  lie 
insi'rted  at  the  ])lace  I  jtropose,  and  directed  somewhat 
forwards,  the  ])eritonenni  and'  colon  will  be  sufficiently  in 
front  to  eseaj)o  injury,  the  liver  will  be  safely  out  of  reach 
above,  and  tlu'  kidney  behind,  while  tho  dilated  pelvis  of 
the  kidney  will  be  tap[ted  at  its  anterior  and  lower  part." 


lU*. 


NEl'lIKfUUllWIIV- 


157 


II  as|)ii':it()r 
III  iiifro- 

(lUtsillc  of 

Ik-  iiijiiri'd, 
(Iniiii  into 
ilt  the  left 
I  that  tlic 
i;lit  sidi-  to 
,  would  lie 
ixiii  of  t!io 
I'lnia,  witli 
I'vsts,  ]iyo- 
lliictiiatiui"^ 
I  introdiicu 
(■i'<ll('  just 
ft   kidney, 

wliiTc,  the 
flit  kidiU'V 
rest  of  the 
nd  a  lialf 
um.  This 
ies  of  the 
jrizoiitally 
lal  kidney, 
ascciuiiiiif 
■ever,  with 
i-uejilirosis 
'  troear  be 
pomewliat 
[leiently  in 
it  of  reach 
1  pelvis  of 
vver  part." 


liaviiiu^  seUvted  the  spot  at  which  to  introdnee  the 
needle,  it"  is  lu'St  to  use  tirst  a  hypoderniie  injection  of 
eoeaiue  and  in.'ise  the  skin  with  a  bistoury,  aft.'r  which 
the  nee.Ue  can  he  pushed  easily  throu.u-h  the  soft  tissues 
without  dantrerof  plun,-;in,-r  it  farther  than  is  necessary. 
It  is  often  necessary  to  make  repeated  aspirations  in  eases 
nf  hvdro-nephrosis  l.i'f<.re  a  cure  is  effected  or  hi'tore 
rcsurtini,'  to  nephrotomy  and  draina,-re  or  nephrictoiuy. 

NKPHIloUUHArilY. 
The  surtrical  operation  for  tlu-  fixation  of  a  movable 
kidiU'V  is  .-'ailed  m'phrorrhaphy.  The  etiolo.uy.  symptoms, 
and  diairnosis  of  movable  kidney,  as  well  as  the  morpho- 
loiiical  difference  between  it  and  tloatint;  kidney,  have 
already  been  studied  in  the  chapter  on  Anomalies  of  the 

Kidliev. 

There  can  be  no  <b.ubt  about  the  propriety  of  resortniif 
to  nei.hrorrhaphy  when  the  imin  and  discomfort  of  the 
movable  kidney  become  very  .irreat,  when  the  mental 
anxietv  is  tellinjr  seriously  on  the  ^ijeneral  condition  of  the 
patient,  when  life  is  in  dansri-r,  or  when  relief  is  not 
afforded  by  the   use  of  banda,!res   and    i.ads  as  already 

advised. 

The  operation,  however,  is  not  unattended  by  danjrer, 
which  makes  an  intelli,i;ent  trial  of  all  other  appliances 
for  relief  of  jrreater  iniportanee.  The  oi>eration  is  a 
comparatively  new  one.  Ilalin  of  Berlin,  in  IHSl,  was 
probably  the  first  to  perform  uephrorrhaphy.  ^fany 
surtroons,  l>oth  in  Europe  and  in  America,  have  since 
performed  this  operation. 

Professor  Keen,  of  Philadelphia,  rev.orts  four  eases 
operated  on  by  himself,  and  ;;,nves  a  synopsis  of  one  hun- 
dred and  thirty  other  eases  operated  upon  in  this  country 

and  in  Europe. 

14 


mamM 


h     I 


ir)8 


I)Isi:asi:s  of  the  Kinsins. 


Tait  ri'ports  tliivf  cast's  dt' tu'iilimrrliaiiliy  in  tlu'  British 
Muli,;il  Jtiiirmil  \'ov  ISSit.  One  patit-iit  died,  aii«l  tiii'  ntliiT 
two  WHTo  not  l)i'n('titod,  Tait  lias  oxjirfsst-d  hiiusolt'  as 
tlioroniflily  distrusted  with  the  operation. 

Mktiiod. — Since  Hahn's  first  operation,  indivichial  oper- 
ators have  nioditied  liis  method  in  aeeonhuiee  witli  thi'ir 
i>wn  views. 

Till'  operation  of  nephrorrhaphy  is  neither  very  ditK- 
eiilt  nor  attended  with  nimli  damper.  AVitli  ordinary 
eare  the  only  accident  likely  to  happen  is  that  of  openini; 
into  the  peritoiu'al  cavity,  which  in  itself  would  not  he  a 
vi'i'v  serious  niatti'r.  It  will  scarc»'ly  hi'  possihle  to  mis- 
take the  liver  for  the  kidney,  as  the  liirhter  color  of  the 
latter  will  he  reco<;ni/,ed.  When  there  is  any  doulit  it 
will  only  he  necessary  to  follow  with  the  Hn<;er  the  out- 
line of  the  origan  in  ipiestiou. 

The  patient  should  lie  on  his  sound  side,  i>ver  a  pillow 
or  support,  in  order  to  make  the  distance  hetwceu  the 
crest  of  the  ilium  and  the  last  rih  as  jrreat  as  possihle. 
IFo  shoidd  also  he  in  such  a  position  that  a  i^ood  liirht 
will  fall  into  the  opeiiiiiir. 

A  competent  assistant  should  stand  on  the  side  oppo- 
site the  operator  and  confine  himself  entirely  to  pressing 
the  movalile  kidney  toward  the  incision. 

The  following  is  (juoted  from  Prof.  Keen's  excellent 
monograph  on  the  suhject  : 

"  An  ol)li(pu'  incision  is  made  hetween  the  last  rib  and 
crest  of  the  ilium,  heginning  ov>'r  the  outer  hordev  of  the 
(juadratus  lumhorum.  Rarely,  i*^'  ever,  will  a  rih  have  to 
he  resected  to  gain  room.  The  ettge  of  the  muscle  heing 
recognized,  the  perinephric  fat  i^  fo'in.l  'vrimediately 
at  its  outer  horder.  This  fat  having  1'>en  .ut  or  torn 
through,  the  kidney  may  he  seen  at  oi.ce. 

"  If  it  is  a  movable  kidney,  but  not  displaced  too  far 


^iM 


NKrUROlilUIAPlIY. 


169 


tlu'  British 

1(1  till'  ntluT 

hiiiisolt'  as 

kidtial  oiH'i'- 
,'  with  tlK'ir 

•  vi  TV  ilitH- 
)i  (inliiiary 
ot'  o|iuiiiiiu; 
lid  not  111'  a 
ililc  to  iiiis- 
rolor  of  the 
iiv  th)iil>t  it 
jer  the  out- 

viT  a  pillow 

ii'twi'i'U  the 

as  possible. 

1  jfood  lii^ht 

'  side  ofipo- 
■  to  pressini; 

I's  fxeelleut 

last  rii)  and 
lordi'v  of  the 
I  ril>  have  to 
iiusvle  heing 
immediately 

L-iit  or  torn 

need  too  far 


from  its  normal  position,  the  movemontw.il  be  se.n  to 
W  svnehronous  with  the  respiration,  and  may  b.  very 
wide  in  extent.  Uut  if  tli.  ki.l.iey  he  far  away  tion,  ,ts 
..ortnal  position,  it  will  not  bo  seen  wlu-n  the  pi'muphne 
fat  is  torn  throu,,d,,  but  nmst  b.  sou.irht  tor,  not  o.dy  b> 
the  tinu^T  in  the  wound,  but  also  either  by  the  hand  ot 
^,,^.  .  ;,,,tor  or  the  assistaut.  on  the  anterior  abdomma 
wall,  i.i  order  to  push  the  kidney  baek  toward  ,ts  normal 

^'''wheu  the  kidnev  is  not  easily  reaehed  and  eannot  be 
pro^^e.!  up  into  tlu'  ineision  by  the  assistant,  it  may  be 
,„„l<,d  bv  a  tenaeulum  or  draw.i  up  by  a  volsellmu. 
llavin-  drawn  the  kidney  into  the  ineis.on,  it  is  h.ve.l  by 

sutures,  eat.irnt  or  silk.  ,     ,        v  .  ,„i.. 

The  sutures  mav  be  passed  throu-h  the  adipose  eaps  le 
alone,  as  llahn  di.l  in  his  tirst  operation  throu-h  the 
fibrous  eapsule  or  the  eortieal  portion  of  the  kidney,  wink- 
some  operators  have  ineised  the  eapsule,  stripi-ed  it  ott, 
ami  passed  the  sutures  th-tr-i.^k  the  eortex.  ^ 

The  kidnev  slmuld  be  fixed  as  nearly  as  possib  e  in  it. 
normal  position.  Both  the  lower  and  the  upper  eud  should 
be  secured,  whieh  will  make  it  less  likely  to  i.iove  with 
the  respirations  or  the  other  movements  ot  the  l.od>. 
From  three  to  six  sutures  are  usually  employed.  In  passni.t; 
the  sutures  throu-h  the  ed-es  of  the  ineision  they  should 
include  a  firm  hold  on  the  muscular  tissue. 

Some  operators  have  passed  the  sutures  around  the 
lower  rib,  a  plan  that  is  certainly  not  advisable.  In  the 
matter  of  sutures,  silk  will  probably  give  the  most  satis- 

faction.  ,        ,         ^  i    u  „ , 

"  The  question  has  arisen  whether  the  sutures  shall  re- 
main temporarily  in  place,  or  whether  they  shal  be  lett 
permanentlv.  I  have  little  doul.t  as  t<.  the  .lesirahilitN  ot 
leaving  them  permanently,  but  in  doing  so  we  must  re- 


ItlO 


Dl.SEASKS  OF  Tin-:  h'lD.XKyS. 


TiifiiilKT  tlio  lari;i'  niiiii^or  of  silk  Iiir:ituns  tluit  liavt-  ^ivon 
risf  to  siiltsi'(|iii'nt  tniulflf,  ('s|icciall_v  in  iil>il(iiiiiiial  siii-sj:*'rv. 
It  is  iiii|>()ftaiit.  I  tiiiiik,  that  the  silk  slioiiM  lie  as  tiiio  as 
j»()ssil)h',  lint  tliick  I'lioiiirli  to  In-  stroll;;."'     (Kcfii.) 

Siiiiif  opcratofs  leave  tulies  tor  drainage  in  tiu-  wouih', 
wiiile  otliers  close  tile  wound  with  sutiiri's,  hut  the  most 
satiKliietorv  method  is  to  leave  the  wound  oiieii  and  dress 
it  with  ixaiize. 

The  after-treatment  does  not  difier  in  aiiv  way  from  the 
tisual  methods  ohserved  in  all  woiintls  of  like  eharaeter. 
The  patiiiit  should  he  ki'pt  (|uiet  for  from  four  to  six 
wi'eks ;  and  it  is  usual  to  applv  an  aeeurati'ly-tittiiiir  haiid- 
aire,  to  he  worn  lor  several  months  atter  the  patient  is  on 
his  feet. 

NKPHIIOTO.MY. 

Nephrotomv,  or  ineisiiiLT  tlu'  kidney  for  the  purpose  of 
evaeuatini;  pus  in  suppuration  of  the  ortraii  or  of  t)iK'nin!j 
cysts,  is  resortecl  to  undi-r  the  following:  eonditions  :  pyo- 
nephrosis, nephro-pyosis  or  ahseess,  oiistruetion  of  the 
ureter  hy  a  calculus,  tuhereular  kidney,  and  such  cases  of 
simple  cysts,  hydatid  cysts,  or  hydro-nephrosis  as  have  not 
boon  cured  by  asjiiration.  ('uttiii<r  down  upon  the  kidney, 
but  not  into  it,  is  necessary  in  ]>eriiu'phritis. 

Where  an  operation  is  re(|uired,  eithv'r  for  suppiurative 
disease  or  for  cystic  conditions,  we  may  tind  the  tluid  so 
near  the  surface  that  the  indications  for  incision  are  aj)iiar- 
ent.  AVhere  no  such  indications  exist,  we  should  place 
tile  patient  in  the  same  i>osition  atitl  make  our  incision  in 
the  same  manner  as  directed  for  nephrorrhaphy.  Always 
bear  in  mind  when  makiuir  the  iticision  that  drainaire  will 
]>('  necessary,  the  tubes  to  be  placed  in  the  most  dependent 
portion. 

When  the  i-yst-wall  is  not  firmly  adherent  to  tbe  renal 
tissues  it  may  be  necessary  to  bring  the  cut  surfaces  of  the 


^Mi 


SEI'linoroMY—NKnina-I.ITIIOTOMV. 


161 


liavf  ^ivt'ii 

lal  siiririi'V. 

)i'  as  tine  as 

■i-ii.) 

till'  wouikI, 

it  till'  most 

II  and  ih'L'ss 

\\\  t'l'diii  lliu 
.'  iliarartor. 
four  to  six 
ittinir  hand- 
tatioiit  is  on 


imrjiose  of 
of  oponina: 
itions  :  pyo- 
tion  of  the 
U'li  casos  of 
as  liavc  not 
the  kiilnoy, 

snpimrative 
the  tlnid  so 
n  are  ai)|)ar- 
hould  phioe 
r  incision  in 
y.  Always 
rainai;e  will 
t  dependent 

to  the  renal 
faces  of  the 


walls  to  the  inaririii  of  the  opening;,  to  whith  they  whould 
he  attached,  if  more  than  one  ahseess  is  found,  the  smaller 
one-;  may  lie  punctured  with  a  nee<lU',  the  openin.i^s  dilatid, 
and  a  drainai^e-tnln'  plact'd  in  each.  The  jjjri'at  ohjcct  is 
to  Sicnrc  a  free  evacuation  of  the  pus  and  at  the  sann' 
time  atlord  the  tncaus  of  antiseptic  irrigation. 

Alter  i\'acliin<^  the  ahsci'sscs  there  will  not  prohahly  he 
mn<li  lieniorrlia<i:e,  e.xeept  in  cases  of  tubi'rcular  kidney, 
when  the  remnant  of  renal  cortex  is  very  vascular  and  had 
hettir  be  torn  with  the  tintjer  than  cut  with  the  knife. 

Small  I'ircumscrihed  ahscessea  are  generally  reached  l»y 
exposing  tlie  capsidi' and  j>uncturing  with  a  line  as{)iratinsf 
needle  until  pus  is  found:  the  punctured  n|iening  may 
then  he  dilati'd  and  the  cavity  waslied  out  and  drained. 

NEPHUO-LITIIOTONJY. 

Xephro-lithotomy  is  the  term  ajiplied  to  the  operation 
for  the  removal  of  a  calculus  from  the  kidney,  its  pelvis, 
or  its  calices. 

This  is  probably  the  oldest  o|)eration  made  upon  the. 
kidney.     It  was  recommended  by  Hippocrates;  but  it  is 
doubtful  whether  in  his  time  the  operation  was  undertaken 
for  the  removal  of  stone  except  where  pus  was  present. 

Xeiihrodithotomy  is  indicated  in  cases  of  troublesome 
h;e!naturia  or  great  pain  and  distress  in  the  region  of  the 
kidney  which  can  be  relieved  only  temporarily  by  medical 
treatment  and  which  are  believed  to  be  caused  by  the 
presence  of  a  stone  in  the  pelvis  of  the  kidney. 

At  best  the  diagnosis  cannot  be  positive.  The  hamia- 
turia  and  pain  may  depend,  as  we  have  already  seen,  \\\)o\\ 
other  coiKlitions.  When  these  symptoms  are  present  and 
the  patient  lias  had  previous  attacks  of  renal  colic  and 
passed  gravel,  or  where  small  particles  of  gravel  are  con- 
stantly passing  from  the  bladder,  as  we  sometimes  see 


mm 


lt;2 


DisK.isr.s  or  Tin:  kidm'.vx- 


wla-n  tlHTc  is  a  riiKulus  in  tl.c  hhuldcr  ..r  in  the  pelvis  of 
tlu'  ki.liH'.v,  the  .liutriiosis  is  iit  least  siiilirii'iitly  .•.Tlaiii  to 
warrant  tin-  operation.  _     ,  , 

MKTHuu.-Thf  Ui.lney  is  i'XiK)se(l  by  tho  lumbur  incision 


Kfiial  I'ulculu.s. 

and  carofitlly  oxaminod  with  the  fino^er  for  eirenmserihed 
indurated  spots,  either  in  tlie  oortex  or  in  the  pelvis,  that 
niisrht  indicate  the  presence  of  a  stone. 


ikM 


M-:i'iii{r.<  Tn.My 


lt;:{ 


1  the  pelvis  (if 
lilly  tHTliilu  to 

imliiir  incision 


3) 

'7 


»r  eircumscrilnd 
.  tho  [ic'lvls,  tluit 


'riic  IvMiicy  i':m  It  prt^sfil  u|i  to  the  tuiirfr  «>l'  \\n- 
opmitor  l«y  an  iis>istinit,  as  In  nciilir<irrlia|.liy.  it'  .xanil- 
nation  l),v  tlif  tiii>rtr  atlunis  no  inili<'atlou  of  tlic  stonr,  tli.- 
kiiliH'V  niav  !(«■  ininctnrfil  \>y  a  lini'  nfftllf  ;  or  if  llif  tiiii:*'!- 
discovers  an  induratnl  spot,  tlu-  ncfcllc  may  ln'  nsc.l  aUo. 
In  many  <'asi's,  liowrvcr,  tlic  stimc  will  prmlncf  suppu- 
ration and  Ik-  finlu'ddfd  in  an  al>s<'css,  wliidi  can  I'l'  easily 
d.t.'.'Icd  with  till'  linu-iT.  I'nlcsrt  several  punctures  are 
niaile,  stones  will  t>ftcn  iscape  detection. 

Wlieii  the  stone  is  found  it  must  lie  cut  down  upon,  ami 
rmioved,  either  with  a  scoop  ov  with  the  fni,u-cr,  ihrouirh 
the  ineision.  or  it  may  he  seized  hy  a  pair  of  foi'eeps. 

Where  the  stone  is  very  larLre  it  nniy  he  hroken  and 
removed  in  jiieces.  The  wound  sho\dd  he  dealt  with  art 
in  nephrectomy  and  nephrotomy.  The  urine  \isually 
escapes  for  a  tin\e  throu^di  the  wound,  hut  should  cease 
tu  do  s<»  in  a  few  weeks.  The  specimen  represented  in 
Fitr.  IS  weit^lu'd  when  removed  foiirteen  ounces,— the 
larircst  stone  I  have  ever  seen.  It  was  removed  hy  my 
confrere,  Prof.  R.  A.  McLean.  Tlu"  nuin  was  surt'eriiiir  a 
irreat  deal  of  pain  in  the  rejfion  of  his  kidm-y,  and  had 
pus  in  the  urine.  The  kidney  was  enlarifed.  On  account 
of  the  .un-eat  size  of  the  stone,  it  was  hroken  durinj;  its 
removal.  The  man  was  eomi-letely  exhausted  hy  the 
disease,  and  consequently  failed  to  react  after  the  opera- 
tion. 

NKrHIlECTOMV. 

Nephrectomy  is  tin-  term  which  desiirnates  tho  o]iera- 
tion  f(.r  the  removal  of  tho  kidney  froni  the  livin-r  hody. 

This  operation  is  also  comparatively  new.  Simon  of 
lleidolhori?  first  iiitentionally  removed  the  kidney  for 
disease,  in  18(in.  Tho  kidney  had  heforo  hoen  several 
times    unintentionally  removed,  tlie   operators    not   sup- 


marnm 


Mil 


i)isi:.\st:s  o/-  Tin:  KinxKi's 


pusiii-r  ill  til*'  liiiif  tliiil  iIk'V  wvw  rciiiovinu:  it.  Thcso 
<.|i.i!iti.>ii>  wtTc  iiiiidf  l>y  iilMloiiiiniil  st'ctioii.  Simon  si-cms 
to  liiivf  l.tiii  llir  lirst  t.t  iii:ikf  tin-  liiiiil>iir  n|M'iiiti..ii. 

The  ciiMs  ill  uliitli  tlic  o|irriiti(>ii  is  iiiiliiiiti-il  aw  tlu' 
tuUuwiiiir:    1,  iiiovaliK-   ixitliu'.v  in  wliidi   lu-plintrriiiipliy 
has  I'aiii'il  !.•  itiaiii  tiic  IxidiifV  in  tlir  iiicisioii ;  -J,  wlu'iv 
lu'iiliionliiipliy  is  iiiiiirafti<'!il>l»'   iKHiiusc  ()f  tin-  «lis(asc»l 
(■..n.rnioii  (.1'  till'  kithifv;   :!,  iiiuvalilc  kiiliuy  wlifri-  w- 
plirorrhapliy  is  iiia.lini>sil»U',  as    tli.'    kidney   raniiut    lu- 
pri'sstil  up  to  or  near  its  normal  position  and  is  I'itlicr 
disi'aM'd  or  trivis  rise  to  so  mucli   pain  as  to  n-ndcr  its 
ronioval  impcrativi- :  4,  lloatiiiir  kidney  that  iv(|uiri's  an 
operation  I'itlu-r  for  disease  or  tor  pain;  ."..simple  cysts, 
hydatid  evsts,  ahseesses,  or  hydro-nephrosis  which  aspira- 
tion and  nephrotomy  liiivo  laiU'd  ti>  cure;   »!,  tuliercular 
kidney  when  tin'  conditions  of  other  orpins  will  alh.w 
of  an  (.peration,— that  is,  when  tuherculosis  is  not  pres- 
ent or  is  not  too  far  advanci-d  in  other  ortrans,  such  as 
tin-    hladder,  the   testicles,   or   the    liintfs,  or   when   hoth 
kidneys  are  not  involved;  7.  primary  canciT,  sarcoma,  or 
non-mali-rnant  tumors;  S,  nephro-lithiasis  when  nephro- 
lithotomy has  faih'<l  to   afford  relief  on  account  of  the 
disori,nini/.ed    condition    of   the    kiilney;    i>,    very  severe 
wo-nds  or   injuries  of   the   kidney,    when    to   leave   the 
ki(:.iU'y  would  he  danjrcr(»us  to  lite  ;  10,  pyi-litis  or  ureteral 
urinary  tistuhe. 

Nephrectomy  should  never  he  performed  unless  the 
operator  is  reas(»nal>ly  certain  that  the  patient  han  another 
kidiu'y  and  that  it  is  not  diseased.  It  is  not  always  an 
oasv  matter  to  diairnose  positively  which  kidney  is  dis- 
eased or  that  only  om-  is  diseased. 

I  assisted  at  a  nephrectomy  not  loniT  as;o ;  the  operation 
was  done  most  skilfully,  and  the  removed  kidney  was 
verv  nuieh   disoriranized.     The   patient   died  three  days 


SEriiiiKtniM) 


HI') 


iii;  it.      IlioflO 

SiiiiuM  mn'iiis 
i|K'i'iiti<)n. 
iiatcil  an-  tlu' 
it'|iliri>nlia|ihy 
*ioii ;  'J,  wluri' 
f  till'  «lis(iisi'»l 
lU'V  wluTo  nc- 
if.v  caimot    Ik' 

aixl  is  litliiT 
s  to  ri'iitlcr  its 
at  rc(|uiri's  an 
1,  siiii|tK'  cvsts, 
■<  wliicli  iiMpiva- 

<!,  tulKTctilur 
ans  will  allow 
■^is  is  not  |»iH'.s- 
(I'ijaiis,  siiih  iw 
or  whtii  both 
tT,  sarroiiia,  or 

wliLMi  m'i>liro- 
in'coiuit  of  the 
i>,  vorv  severe 
1  to  leave  the 
litis  or  ureteral 

led   unless  the 

Mit  has  another 

not  always  an 

kidney  is  «lis- 

I ;  the  operation 
•ed  kidney  was 
lied  three  days 


after  the  operation,  when  a  posi-niortiin  n-Vi'aled  the  tint 
that  tlie  retnaiiiini,'  kidiny  was  in  a  nnnli  worse  londition 
tlian  the  one  that  had  heeii  removed.  This,  nnfortii- 
nately,  is  not  the  only  instanee  of  the  kiml.  'I'lie  east-s 
in  which  the  ditfeniitial  diairnosis  is  found  to  he  the  most 
ditlieult  ari"  those  of  pyuria  where  the  pus  is  evidently 
iVom  the  kidney  and  where  neither  kidney  is  eiilarired  nor 
one  inm-h  mor*'  tender  than  the  other.  Several  methods 
have  heeii  suji'iTi'sted  for  diseovei'iuLr  from  which  ureter 
the  pus  is  eseapini;  into  the  iiladder. 

Catheteri/inir  the  ureters  has  heeu  resorted  to. — a  jiro- 
eetlure  that  may  occasionally  lu'  adopted,  hut  whi<  h  will 
never  he  of  much  pra<-tical  value,  from  the  dilHculty  of 
its  accomplishment.  It  has  also  Keen  proposed  to  open 
the  hladder  hy  tin-  supra-puliic  operation  and  e'.ilur 
eatlu'teri/.e  the  ureters  or  ol)serve  the  outtlow  <<f  pus. 
A'Min,  the  eiidoscoiu'  has  heen  hrouirht  into  re(piisition 
and  has  sometimes  yiehled  valualtle  infornnition.  I>ut, 
like  catheterization,  it  will  prohahly  nt'ver  come  into 
j;eneral  use  tor  this  purpose. 

The  kidney  ean  he  cut  down  upon,  exposed,  and  tx- 
amine<|,  hut  as  a  <liairnostic  measure  this  may  l»e  said  to 
be  heroic;  and  should  the  kidiu'y  be  found  to  be  diseased 
there  is  a  possibility  of  the  other  one  beini:  in  a  worse 
eoudition.  There  must  always  be  a  small  perci'UtaLre  of 
eases  in  which  it  is  impossible  to  be  absolutely  positive 
whieh  kidney  to  remove. 

It  is  somewhat  surprising  to  find  Morris  makiui;  the 
statement  that  nephrectomy  for  cancer  will  probably  be 
abandoned.  For  secondary  canci-r,  of  course,  if  shoidd 
not  he  attempted;  but  for  primary  cancer,  except  in 
younj)^  ehihlren,  the  operation  will  probably  become  more 
ap]»reciated  and  will  be  oftener  resorted  to  in  the  near 
future. 


ma^ 


ii'.t; 


nisi:.\si:s  "/•  rin:  k//'.vk)-.v 


>a1 


M      .  ,       Tl...  ki.lii.v  'h  us.mlly  ivmovr.l  l.y  ..i... 
''"'■'  :';ri^^i.-l..rn.rl.nVtou,v  ana  alHl.Hun.al 

'^^V:"        :  ;;.    i>.u.-v    mIhI....!  is  tl -uaUy 


|)i.rit.iii«uiii   ii'Ti 


t;l,L..  h,,..  .1..-  M..l...uinM  ...vuv W,  l-ll. 

■  '<«-'••■'-'""!'■  ^■;';;;;,' ■;.,. ,---.- 


•  1' 

("(iHlUli'lH-f  till' 


„.|„.m.v,T  •..  will  ..ll.-.-  ll-  ,-"■"'<-'    ■     "      \  I  ,,.  „„„. 

•n- i^"i-.v  1; '^  ;;::;,■;::'';,,.,,  iiHi.-..r  no 

,,,,n„.rlM"--     II"  «„,-,.,■.  will,  liul.-  "'■  "" 


,.ust.mKirvto|.:\ss  tlu'  lii 


..ust.muiry  to|.ass  uu   i>^-  T'..- .UtHcultv  of 

this  ,.1-o.H.auiv  usuallN  .1  1"  MM  _   M  l»assinu'    a 

tviiiiX  Olio  faeli  \miv  l^  n'l-  ^ui^-iv 


■-) 


SI'.l'llltlU  T'lMV 


If.T 


ril  l>y  I'll*'  <>r 
mil  alHloiiiinal 
„.  ,iiic  u^uiilly 
i.  lattir:  K  ''"' 
iiii-rt-  from  tliii 
riality  is  U'ss; 
1^  oUviatfd  ;  '», 
I  viiiilfd.  li"lli 

lit  tor  iiriiliror- 
atois,  liowi'Vfr, 
rst   InntiitiMlinal 

As  sati>t'ai'tory 
.  till-  iial'unt  in 

("(iiiiiiu'i\fc  tho 
ACT  ril>,  niiiniu.i? 
„,si'  tlu'  kiiliuy  : 
iK',  if  iK'ci'ssary, 

t(.  tlu-  oju'i-ator. 

JH  ri  atlily  ''iiii- 
H'vw  littlr  or  no 
,•1,  ..iivmiistaiu'i'rt 
^vitli  littK-  or  no 
wlu'tv  tluTi'  has 
•V  I'Utiivly  airu'ln- 
md  llu'ir  sfjiara- 

rrliaiX*'- 

tin-  lijxatnri',  it  i^^ 
lie  nrt'tiM-  and  tin* 

T'le-  dilHculty  of 
>  amount  of  adlie- 
siu's.  Tassinir  ii 
■isnial  Ui'odK"  and 
easiest  nietliod. 


Wlinv  no  adlu-sions  exist,  tli.>  kidn.y  is  witlioiit  dilli- 
ndtv  drawn  n|>  snllirimtly  t..  all..\v  tl..'  liiialmv  to  lu- 
^,Y,'lM'i\  well  down  nj.on  llie  p.diele.  so  that  on  renioviiijj 
iIh.  ki.lnev  enou.!;h  «.f  the  pediel-  will  ivinain  t,.  pnvmt 
thr  iijratniv  iVoii'i  .lippin,-;  otV.  A  seeoi.d  lipitnre  .an  !..• 
thrown  over  I  ..■  mtire  prdirh'.  whi.h  will  add  to  it. 
MTiirity.  The  iM.li.le  >honhl  then  \n-  divid.d  and  the 
kidn.v  nmov.d.  The  wo.md  must  he  drawn  uril  opni. 
iiiHl.  with  Ih.'  ai.l  of  a  ,-ood  li.irhl  thrown  into  ih.'  '....tton. 
..I'llir  iii.'isioii,«-very  hieedin-r  artery  imist  he  liiial.'.l  with 
line  silk  or  .atirnt.  '  The  iid'.iior  renal  artery  is  likely  to 
lie  the  most  tronhh'some. 

The  liiriitures  are  «ut  riose,  the  wonii.l  is  washed  out 
with  an  antiseptic  s..hitioii.  drained  hy  m.'ans  of  tuhes, 
,,n,l  the  in.-isi..n  j.a.'ked  with  antisei^lir  v^nnw  or  its  »'<l,ires 
l,rmiu;ht  toirether  hy  sntnres.  The  patient  sl.onld  he  kept 
pcrfntly  ipiiet,  and  ii  hamla-j*'  "•!•  pad  ai.plied  when  he 
,,,iiHm'm'es  to  walk  ahont,  as  recommend. •.!  in  cases  ..f 
iiephrorrhaphy  and  nephr.)tomy. 

Where  ther".'  is  ,trreat  dilH.Mdty  in  applyin.ir  the  li,i:aHires, 
u  stroniT  Inenmstatic  forceps  with  a  well-curved  handle 
iiMirht  (iiiviate  the  mri'ssity  for  a  li.irature,  just  as  we  uso 
the  lontr-jawed  forceps  in  hysterect..my  without  resortint,' 

to  a  liii'ature. 

Ahdominal  nephrectomy  is  not  often  performed  at 
present,  and  is  to  he  preferred  in  very  few  cas.s,  .)ne  of 
which  is  for  the  removal  of  tloatint;  ki.lney.  It  presents 
(M.e  a.lvanta.ire  in  the  tact  that  the  otla^r  ki.lney  .aii  l.e 
examin.'.l  before  the  removal  ..f  the  one  (h'sired.  The 
usual  incision  in  the  m.-.lian  line  can  he  ad.^pted,  or, 
what  is  njore  common,  th.'  incisiun  alonir  tlie  .mter  horder 
,,f  the  rectus  muscle  on  the  side  from  which  the  kidney 
is  t..  he  removed.  The  operation  in  this  case  is  to  he 
conducted  (»n  the  same  principles  as  any  other  laparotomy. 


SECTION    IV. 

DISEASES  OF  THE  BLADDER. 


(•II  A  I'TKU    I. 

AN.\H>MN     <ir    Tin;    lll.AlUiKlt. 

HilFoui';  fdiiiniciiciiiir  llu'  stmlv  ol'  tin'  iialiiolnijiciil  cnii- 
tlilidiis  of  this  ofLran  it  will  ln'  well  to  nvitw  its  iniiiripiil 
aiiiiliiiniciil  Itatiirts. 

Tlic  hladtU'r  is  a  imisciilo-i'H'iiiliraiious  sai-,  siliiatnl  in 
til.'  prlvis  iK'twrcii  tlic  |.iil»is  and  ri'ctmii  in  tii*'  iiial.'  ami 
iu'twci-n  tlic  |tnlii's  anil  vairina  ami  ntfiiis  in  the  rmiaif, 
its  sliapi',  position,  ami  ri-latioiis  luinn'  iiitlni'ncnl  hy  ai;f, 
Si'X,  and  dti;rir  of  disti'iition  of  llif  origan.  In  inliim'V 
and  rliildliooil  it  is  conical  in  hIuiju',  the  vortical  diameter 
bciut;  tlic  lonirer.  In  the  female  it  lias  a  i^rcatir  lateral 
than  vertical  iliameter.  In  old  aire  the  vertical  diameter 
airain  hecomes  tlu'  Ioniser,  while  in  adnit  life  when  t|niti' 
empty  and  contracted  it  is  triaiiirular  in  shaiie,  place<l 
deeply  in  the  pelvis,  tlatteiied  from  Itefore  hackward,  and 
reaching;  as  hii^li  as  tl.c  npper  horder  of  the  symphysis 
pilhis. 

When  slii^htlv  distended  it  is  rounded  in  form  and  still 
remains  in  the  pelvic  cavity,  Imt  when  <;reatly  distt'ndi'd 
it  hecomes  ovoid  and  rises  into  the  ahilominal  cavity, 
often  as  hiirh  as  the  nmhilicns. 

When  moderat-'y  distended  it  measure's  about  five 
inches  in  leiiirth  :Mid  three  inches  across,  and  ordinarily 
it  contains  ahoui  a  pint. 

108 


^Ml 


>|u!;it'!il  coii- 
its  iirlii<'i|iitl 

',  siliiiiti'tl  ill 
lie  male  iiinl 
I  tile  I'rillilli', 
licril  hy  iin'f, 
III  ililiility 
(111  (liiiiiutcr 
».jit»i'  latniil 
I'ul  tliaiiu'trr 
■  wIm'Ii  (|iiiti' 
liaiii',  plao'il 
ckwanl,  aiitl 
I'  syiiiphysis 

)rin  and  still 
tly  (list»inlf<l 
iiiiial   cavity, 

^  alioiit  livt." 
1(1  otiliiiarily 


.ivi7v»vi    nr  Tin:  iii.u>ni:i{. 


169 


'n„.  l.l.i.l.l.r  |(.r  ...iivniinicf  <.f  .li'srn|.ti.m  nuiv  l»i' 
diviil.d  iiitd  Hiiimiit,  iM.dy.  l-a-c,  ami  ii>«l--. 

Tlu-  .Mininiit,  or  a|K-x.  i^  n.mi.l.d  and  diiv(  I.  .1  tuiwurd 
,,nd  upward.  Ii  i-  .■..iiiu'.t.'d  with  tl.r  iniil.ili.M>  l.y 
,|„  iinudius  and  lli<'  ..l.litciat.d  |M.rti..iir.  ..f  the  livj...- 
■  rastri.-  artfiW.  Tl.M  i...rti..n  ..f  tin-  .iiininil  wln-li  Ins 
Uliind  tlic  iiia.liM:  i-  .-..vrivd  l.y  i.rnl..nriiiii,  Nslmli  is 
wanlin-;  »u  tlir  p..rtiuii  anIiTiof  to  it  wliith  ivsts  a-rainst 

tlic  alHloiiiiiial  wall. 

Tlic  l...(|v  (.f  llic  l.la.l.hT  is  that  pcrticii  whnh  Ins  h.- 
tu.cn  the  ap.-x  and  the  wsical  ..p.nintrs  nf  the  uivtiTS, 
li  i^  n-.l  (c\«'rcd  in  tV..nl  l.y  prrilciniini,  and  is  in  ivlii- 
tioM  hnv  with  the  trianirnlar  li,u'aiinnt.  the  pnstt'i'ior 
Hiirfa.v  ..r  the  sviiiphv>i>  pnl.is,  tho  intiTiial  ..l.tnialur 
iiiusrii-s,  and,  win-n  disfndrd.  with  the  al.d-.n.inal  wall. 
Tin-  p.ist.-ri.»r  surface  is  .(.iiiph-trly  (•..v.icd  l.y  p.ri- 
t..in-uni.andisin  n-lati-.n  with  tin-  ivHuin  in  tin-  niaU- 
and  with  tin-  utt-rus  in  tin-  f*  inaU-,  s..iin-  r(.nv(.lntn.ns  ot 
Hiiiall  iiitt-stiiR-  l.cinj;  int»-rp(.sfd. 

Tin-  has.-,  ..r  lundus,  is  directed  d..wnwar.l  and  hack- 
ward,  and  is  that   part  which   lies  helow  the  plain-  whi.-h 
marks  the  level  ..f  the  h..dy.      In  tin-  male  it  rests  up..n 
the  second  p(.rti(.n  ..ftln-  rectum,  and  is  partially  o.vercl 
hv  pei-itoneimi.  which  is  rcllectcd  ui-on  tin-  rectum,  t..rm- 
i,;,.  the  rect..-visical   lul.l.      in  tin-  female  it  is  in  relatn-n 
with  the  h.wer  i.ait  of  the  cervix   nteri,  and  in  a.lhercnt 
to  the  anti-rior  wall  of  the  va.irina,  a   foM  ..f  pent(.ncum 
iutervenint;  hetwciii  it  ami  tin-  upper  part  ..I   the  anierior 
surface  ..f  the  c.-rvix.     Tin-  most   important   port  ions  ..t 
the  hodv  are  that    portion  which   Ihs  l.etweeii   the  vesn-al 
opeiiin-s  <.f  Ihe  uret(-rs  heliind  and  the  vesical   ..rdice  ot 
tl.c  urethra  in   fn.nt,  which  is  km.wn  art  the  v.-sical  tn- 
aiiirk-,  or  tri^irone,  and  that  portion  of  tin-  has.-  which  lies 
lust  liehind'the  urct.-ri.-  ..p.-nin.t-s,  called  the  has-foiul. 


«ww«>«;w«i»!f  »»"'>'E»''»'***^'"'"" 


170  DISKASES  OF  rilE  BLADDER. 

Tlio  (HTviN,  or  •H'.'k,  is  tluit  .(.ustncto.l  portion  of 
th,  ap.x  of  ti.o  tri-one  wliirh  is  ooi.tinuous  w.tli  the 
urothra.     In  the-  niak'  it  is  surromuUd  l.y  tlit-  prostate 

'"''Ai-.'or.lin-  to  souk-  autliors,  the  l^hi.hler  is  eomposed  of 
thr...  eoats;  Ciray,  however,  nanies  tour  -s.rous  (whu-h 
i.  hut  in.rtial),  nmseular,  suhnuu-ous,  and  n.neous.  1  he 
sc.rous  „r  peritoneal  eoat  eovers  tlie  posterior  surtaee  trom 
opposite  tlie  opening'  of  the  nreters  to  the  sunnnit,  an.  ib 
r'.tieeted  0,1  the  pelvie  and  ahdominal  walls,  tor.nn.-  the 
false  ligaments. 

Tlu'  nmseular  eoat  eonsists  of  several  h-yers -an  ex- 
ternal laver,  in  whieh  the  iihres  are  arranged  lon^ijUu<li- 
nallv,  a  "nnddle  layer,  in  whieh  they  are  arran^'ed  m  a 
,i,,;Uar  manner,  and  an  internal  layer,  m  whieh  they 
a-ain  have  a  geueral  longitudinal  arrangement  lie 
iihres  01  these  layers  interlaee  so  elosely  that  praetioally 
thev  niav  be  eonsidered  as  one  layer.  Toward  the  lower 
paA  of  ihe  bladder  the  cireular  fibre,  are  closely  aggre- 
gated, forming  the  sphineter  vesieivs  whieh  in  the  mal'  is 
eontinuous  with  the  prostate  gland. 

Two  bands  of  obliqne  fibres,  known  as  the  museles  ot 
the  ureters,  take  their  origin  just  behind  the  ureters,  and 
converge  to  the  baek  part  of  the  prostate  gland  where 
thev  ai-e  inserted.  They  weie  formerly  supposed  to  pre- 
vent the  reflux  of  urine  into  the  ureters,  but  j.robably 
thev  have  little  if  any  special  action. 

The   submucous   coat   consists  of  a  layer   ot    areolar 
tissue  connecting  the  muscular  and  mucous  coats,  and 

vcrv  adherent  to  the  latter.  •  ,    .1    ,    p 

The  mucous  coat  is  thin  and  continuous  with  that  ot 
the  ureters  and  the  urethra.  It  consists  of  a  basement- 
membrane  supporting  several  layers  of  epithelium,  in  some 
parts  squamous  and  in  others  cylindncal.     It  is  ..)Osely 


0(1  portion  of 
nous  with  the 
)y  tliC!  jirosttite 

is  composefl  of 
—serous  (wliich 

mucous.  The 
ior  surtiu'c  tVoni 

surinnit,  uud  is 
Us,  tbriiiiug  the 

I'-yers,— an  cx- 
tUgod  h)ngitu<li- 
i  arranged  in  a 

in  which  they 
ngenient.      The 

tliat  practically 
Dward  the  lower 
i-e  closely  aggre- 
.'h  in  the  mal  >  is 

19  the  muscles  of 
.  the  ureters,  and 
ite  gland,  where 
supposed  to  pre- 
srs,  hut  iirobahly 

layer  of  areolar 
ucous  coats,  and 

lous  with  that  of 
ts  of  a  hasement- 
)itheliuni,insonie 
eal.     It  is  l')Osely 


AXATOMy  (>!■    TllK  BLADDER. 


171 


attached  to  the  muscular  coat,  except  at  the  trigone,  at 
the  neck,  and  al>out  the  oritices  of  the  ureters. 

It  is  provided  with   mucous  glands  and  tolhcles,  not 
vcrv  numerous  excepf  'i>«>'»t  ^he  vesical  neck.    On  account 
ol'  Ihe  looseness  of  the  attachment  of  the  mucous  coat, 
wlien  the  hla.hler  is  not  disten<led  it  is  thrown  mto  tolds 
except    .<t    the    points    of   close    attachment.      Projecting 
from  the  lower  anterior  part  of  the  hla.hler  into  the  orihce 
of  iie  urethra  is  a  slight  elevation  of  mucous  memhrane, 
called  the  uvul'i  vesioe,  whicli  is  hut  little  developed  m 
the  female.     The  arteries  supplying  the  bladder  arc  1:ho 
sui-erior,  middle,  and  inferior  vesical  in  the  male,  with 
additional  branches  from  the  uterine  and  vaginal  m  the 
female.     These  are  all  derived   from  the  anterior  trunk 
of  the  internal  iliac.     The  anastomosis  is  very  free,  the 
.,bturat,.r  ami  sciatic  arteriesalso  supplying  small  branches. 
The  veins,  after  forming  a  complicated  plexus  about  the 
neck,  sides,  and  base  of  the  bladder,  terminate  in  the 
internal  iliac  vein. 

The  nerves  of  the  bladder  are  derived  from  two  sources, 
the  sympathetic  and  the  si»inal. 

The  sympathetic  are  hraiu'hes  from  the  hypogastric 
plexus,  which  also  supplies  the  vagina,  uterus,  and  rec- 
tum ;  while  the  spinal  are  derived  from  the  ibiirth  sacral, 
occasionallv  the  third,  and  rarely  the  second.  ^ 

The  nerve-supplv  is  particularly  rich  to  the  small  tri- 
angular space  known  as  the  trigone,  which  is  the  most 
seu.-'tive  part  of  the  bladder. 

1..  bladder  is  retained  in  place  by  ligaments,  which 
are  divided  into  true  and  false,  there  being  five  of  each. 
Of  the  true  ligaments  the  tv  ?  anterior  extend  from  the 
back  of  the  pubes,  one  on  each  side  of  the  symphysis,  to 
the  front  of  the  neck  of  tb  >  bladder;  the  lateral  are  at- 
tached  to  the  sides  .  f  the  base  of  the  bladder  and  the 


172 


DISEASES  or  Till-:  liLADDF.It. 


lateral  partK  of  tlic  prostata;  and  the  urachus,  a  tiltro- 
imiscular  cord,  oxtciids  between  the  hu  niuit  and  the 
nmhilicns. 

The  t'alrte  li«!;anients,  composed  ot"  reflections  of  the  peri- 
toneum, are  the  two  j)osterior,  which  i)ass  forward  from 
the  sides  of  the  rectum  in  the  mali;  and  of  the  uterus  in 
the  female  to  the  posterior  and  hiteral  aspect  of  the  hiadder, 
and  contain  the  obliterated  hypogastric  arteries  and  ureters, 
togother  with  vessels  and  nerves;  the  two  hiteral,  from  the 
iliac  fossa  to  the  sides  of  tlie  bladder;  and  the  superior 
fold  of  peritoneum,  extending  from  the  summit  to  the 
umbilicus  and  covering  the  urachus  and  the  obliterated 
hypogastric  arteries. 


t 


CHAPTER    II. 


CYSTALGIA. 


The  bladder,  like  the  other  hollow  viscera  of  the  body, 
is  subject  to  diseases  and  to  disturbances  of  both  its  motor 
and  its  sensory  nerves.  We  will  first  take  up  the  subject 
of  its  nerve-disturbances,  beginning  with  cystalgia,  or 
neuralgia  of  the  bladder. 

Etiolo(jy. — In  many  cases  neuralgia  of  the  bladder  is 
produced  by  stone,  concretion,  or  other  foreign  bod  v. 
Sometimes  it  is  the  result  of  the  chemical  condition  of 
the  urine,  that  secretion  being  alkaline  or  perhaps  exces- 
sively acid.  We  often  find  patients  having  severe  neu- 
ralgia of  the  bladder  ,vhich  is  purely  reflex,  the  disease 
being  of  the  rectum, — fissure  especially, — or  of  the  urethra. 
Stricture  in  the  male  and  caruncles  in  the  female  are  the 
most  frequent  urethral  causes.     I  have  seen  people  of 


CVSTMOIA. 


173 


I'liUH,  11  tiliro- 
iTuit    and    the 

IS  of  the  |K'ri- 
forwanl  from 
the  uterus  iu 
f  theldiuhh'r, 
•sand  ureters, 
eral,  from  the 
the  superior 
immit  to  the 
le  obliterated 


of  the  body, 
oth  its  motor 
ip  the  sul)jeet 

ejstalgia,  or 

le  bladder  is 
breigii  body, 
condition  of 
erhaps  exees- 
^  severe  neu- 
:,  the  disease 
if  the  urethra. 
3male  are  the 
jn  people  of 


.routv  diathesis  suffer  from  violent  attacks  ot  eystalo;,a. 
Surli  attacks  are  presunuibly  the  result  of  an  excessive 
a.iditv  of  the  urine,  or  they  may  arise  from  the  same  cause 
that  creates  disturbances  in  the  other  hollow  vis.-era  ot 

such  sulyects.  ,.<.,-    ,-,„f 

It  is  not  infre.pient  for  one  who  is  the  subject  ot  .tcout 
to  have  violent  attacks  of  asthma,  -astralgia,  or  enteralsia, 
with  diarrlm-a  or  oystalgia.  Perhaps  in  all  these  cases  the 
ivspcctive  mucous  membrane  involved  eliminates  urate  ot 

sodium.  .     ,         .,,  , 

Occasionallv  a  person  sufferini?  from  sciatica  will  have 
a  VK.lent  attack  of  eystalgia  accompanying  or  alternating 
with  the  sciatica,  owing,  no  doubt,  to  the  tact  that  a  vis- 
ceral branch  is  given  off  from  the  third  sacral  nerve  to 

the  bladder.  .         ,.  , 

Cvstal-ia  may  be  the  result  of  ulceration  ot  the  mucous 
nuMubrane  of  the  bladder,  just  as  gustralgia  is  caused  by 
a  chro,  •  irritable  ulcer  of  the  stomach.  [  know  ot  no 
reason  whv  the  bladder  should  not  oc(.asionally  sutter  from 
malarial  neuralgia,  as  does  every  other  organ  ot  the  b..dy. 
I  feel  (luite  sure  that  whenever  a  case  of  severe  eystalgia 
presents  itself,  if  the  practitioner  will  keep  well  m  mmd 
its  etiology  and  carefully  examine  for  one  of  these  causes, 
lie  will  verv  seldom  he  obliged  to  call  it  idiopathic. 

PATiiOLO^Y.-It  is  quite  apparent  that  the  path<)logical 
condition  of  tlu  bladder  must  depend  upon  the  etiology; 
that  is,  the  pathology  may  be  in  the  urine  itself,  or  it  may 
be  in  the  urethra  or  in  the  rectum,  or  stone  may  be 

^"SYMPTOMB.-Puin  is  the  pathognomonic  symptom  of 
neuralgia,  whatever  organ  or  nerve  be  involved.  In  eys- 
talgia the  pain  may  be  constant  or  paroxysmal  and  accom- 
panied by  violent  spasms,  in  whi(-h  case  it  is  usually  desig- 
nated by  the  term  cystospasmus  rather  than  eystalgia. 

16* 


^^vr^' 


w 

1!" 


174 


DISEASES  or   THE   lU.ADDi.lt- 


AVitli  i!k'  cystal-ia  tluTo  is  liUfl.v  t..  Uo  u  (■.)nstant  dosire 
to  inu-turaU"  or  aii  iiiahililv  to  ivtuin  the  uriiK-. 

TiiKATMKNT.— Tlu'  iiidicutioMs  tor  ti-'jiitmont  arc  to  allay 
tho'i.ain  a.i.l  ivmovc- tlu- causo  :   ivmovin,!,'  stoms  or  iWr- 
c-,.n.  l.o.rus  as  the   ease   may  he;   treatiu-  the   -out   (.r 
malaria,  also  the  reetum  or  urethra  where  the  aiieetiou 
is  retlex,  or  the  uleeratiou  of  the  hladder  when  that  .•on- 
(liti.mh  i"-^'^^'"t;  examiniu-  earefully  the  ehemual  e.m- 
(litiou  of  the  uriue   aud   eorreetiu.t;  it,  if  ahuormal,  hy 
arids  or  alkalies  as  indieated.     For  the  relief  of  lunn    [ 
have  found  opium  and  hyoseyamus  the  two  most  reliable 
druus,  and   their  administration  in   the   form   ot   reetal 
suppositories  the  most  satisfaetory  method.     For  the  im- 
mediate relief  of  severe  eystal-ia,  T  am  in  the  hahit  ot 
orderintj  suppositories  eontainiuK  one-half  i,n-ain  ot  mor- 
phine and  ttve  grains  of  extract  of  hyoseyamus,  with  heat 
applied  over  the  bladder. 


CHAPTER    HI. 

IIYPER.ESTIIESIA  (IRRITABLE    BLADDER). 

This  is  another  aftection  of  the  sensory  nerves  of  the 

bladder.  ,      ^  i    1 1    1 1 

Etiolo.jy.— The  etioU.gv  of  hypcra^sthesia  of  the  bladder 
is  sometimes  verv  apparent,  at  other  times  it  is  obscure. 

It  may  be  either  the  result  of  irritation  of  the  peripheral 
extremities  of  the  sensory  nerves  of  the  bladder,  or  en- 
tirely reflex. 

The  iinm"^=  te  irritation  is  often  caused  by  concretions, 
foreign  bou.es,  or  growths  in  the  bladder,  which  simply 
produce  irritation  without  inflammation. 


ll-lWfMlM-''    ■fUtU-'l.'^'-- 


iiyri:ii.KSTiii:xiA. 


175 


I'oiistunt  (U'sire 

•iiH'. 

L'lit  are  to  iiUiiy 

stones  or  t'or- 
;j;  tlio  j;out  or 
i.'  tho  iitit'ction 
wlu'ii  that  coii- 

I'lK'iuiral  eoii- 
'  abiionnal,  l>y 
rt'lu't'of  l»ain,  I 
o  most  reliable 
fori  11  of  rectal 
1.  For  the  im- 
111  the  habit  of 
f  ijraiii  of  mor- 
uuus,  with  heat 


dder). 

'y  nerves  of  the 

lia  of  the  bladder 
s  it  is  obscure. 
;)f  the  i)eripheral 
bhuhler,  or  eu- 

\  by  coiicretioiirt, 
er,  which  simply 


\t  other  timert  the  hvpenestliesia  sivms  to  depend  upon 
an  abnormal  con.riti..ii  of  the  urine,  which  may  be  cou- 
,,,,„, .,,,,,1  and  hi-hly  acid  or  else  excecdm-ly  alkaliiu'. 

The  urine  of  <liabctic  patients  is  sometimes  .-xtrcmcly 
i,,itatin-,  as  is  also  that  which  c.ntains  oxalatc-ot-linie 
ervstals."  Patients  of  -outy  diathesis  are  liable  t(,  this 
nmdition,  wliich  is  probably  caused  by  the  hi-hly  acid 

'"  Patients  with  hypertrophied  prostatic  glands  are  con- 
stant sufferers.  „ .    .     ^.       •     u 
We  not  infrciueiitly  tind  the  source  of  irritation  in  the 

spine  or  the  brain. 

Pre-uancv,  especially  during  the  first  few  months,  and 
mcrine  disease,  arc  frequent  sources  of  irritation  without 

iiitlammation.  ,  ,   ,.  x 

Of  the  reflex  irritations,  hemorrhoidal  disease  seems  to 
,, lav  the  most  prominent  part,  while  many  patients  who 
aie  subjects  of  stricture,  caruncles,  or  iuflammatum  ot 
tl.e  urethra  suiier  great  annoyance  from  a  puri'ly  irritable 
bladder.     In  bovs,  phimosis  is  a  frecpient  cause. 

In  portal  obstruction,  in  malarial  liver,  or  m  passive  or 
active  congestion  or  organic  disease  of  this  organ,  the 
vessels  of  the  bladder  become  turgid,  impinge  upon  the 
nerves,  and  produce  much  irritation. 

Symptoms.— The  i.athognomonic  symptom  ot  hyperfes- 
thcsia  is  of  course  the  intolerance  of  the  bladder  for 
mine  when  there  is  neither  inflammation  nor  ulceration 
present.  The  patient  has  no  fever  and  little  or  no  pain, 
but  suflers  the  great  inconvenience  of  constant  desire  to 
micturate.  Unless  prostatic  enlargement  or  stricture  is 
1  •resent,  there  is  no  straining  and  little  tenesmus. 

Treatmknt.— The  indication  for  treatment,  after  being 
satisfied  that  no  inflammation  is  present,  is  to  render  the 
bladder  t(derant  of  its  contents.     This  we  can  do  only 


w 


176 


I)Isi:asi:s  or  the  uladdf.r. 


l 


urtir  .iint'iil  iiH|niry  into  tlic  i'tiolo.iry.     It'  the  coiiditioii 
is  caiisiMl  l>y  clK-iiiinil  .lian.ircs  in  the  urine,  thcci-  must  be 

obviated. 

In  ease  of  coneentrate.l  lii,i,^lily  aiid  urine,  iiiilil  diuretic 
alkalies  W()\ll(l  be  likely  to  meet  Hie  indieatioii,  wliieh  is 
to  increase  tlie  (iiumtity  of  urine  and  elian^'e  its  (luality. 
This  form  of  irritable  bladder  is  more  often  than  any 
other  successfully  treated  by  the  administration  of  alka- 
line luiueral  waters.  In  Kurope  such  patients  are  sent  to 
Carlsbad,  Vichy,  or  some  other  noted  \vaterin,«;-iilace,  but 
here  in  California  we  have  the  best  of  waters  at  our  own 
door,  — Napa  Soda,  Hartlett,  yKtna,  Coronad(»,  Viehy, 
Shasta,  and  many  others.  As  a  substitute  tor  mineral 
water,  the  followinj,'  mixture  will  often  act  like  a  charm  : 

B    I'dtassii  iicctiilis,  Jvi-viii; 
Spt.  ii'theris  nitiosi,  giv; 
Tinct.  hydscyiimi,  .^i; 
Syr.  ci.dfi,  ^'\ ; 

Aquic  chlorofornii  lul  _^i.— M, 
gi<r._gi  every  two  lioiiiv,  wi'll  diluted. 

Bicarbonate  of  potassium  or  bicarbonate  of  sodium 
may  be  substituted  for  the  acetate,  and  infusion  of  bella- 
donna or  fluid  extract  of  triticum  repens  for  the  hyos- 
cyamus. 

"  For  the  irritation  accompanying  projLCnaucy  I  have  been 
in  the  habit  of  prescribing:  the  following : 

B   Spt.  irtheris  nitrosi, 

Tinct.  liyf'soyami, 

Glyccrini,  aa  .^i. — M. 
Sisr. —  3  i  every  two  hours. 

This  last  prescription,  with  a  few  directions  as  to  diet, 
will  in  most  cases  allay  the  irritation  of  pregnancy.  In 
other  •  cases  it  may  be  necessary  to  give  a  suppository  of 


Eawts»»sw«i*r*»«K'»*'«<«»e'*'^' ' 


n. 

It'  the  condition 
e,  thfci!  must  be 

10,  milil  diuretic 
ciition,  wliicii  irt 
in_u;<.'  itr^  (luality. 
often  than  any 
stration  of  ali<a- 
[ionts  arc  sent  to 
iti'ring-placi',  hut 
ivtera  at  our  own 
oronado,  Vichy, 
tutc  for  niinLM'al 
ict  liko  II  charm  : 


iiij  i:ii.EsTiij:siA. 


177 


uted. 

Miato  of  sodium 
infusion  of  bclla- 
•ns  for  the  hyos- 

laney  I  have  been 


ections  as  to  diet, 
)f  pregnancy.  In 
e  a  suppository  of 


hyoscyamus  and  morphine  at  bedtime,  or  tlie  prescrip- 
tion ("ontainintr  acetate  (»f  potassium  already  nu'ntioned, 
wliile  some  .h-rive  great  benefit  from  hot  vaginal  douches 
,,1-hot  rectal  encnuita.  Cream  of  tartar  tea— that  is,  a 
saturated  solution  of  cream  of  tartar  in  hot  water,  allowed 
t,.  cool  and  nuido  pleasant  to  the  taste  with  a  littU-  sugar 
_is  a  lavorite  prescription  of  mine  for  the  irritai>le 
hladdi'r  of  prciruancy.     > 

Triticum  repens  tea  will  often  answer  the  p>iri)ose 
admirably;  l>ut  a  remedy  which  must  never  be  forgotten 
in  irritiib'le  bladder,  no  matter  what  the  cause  of  the  irri- 
tati..n,  consists  in  snudl  doses  i.f  chloral  hydrate,  two  or 
three  u;rains  every  two  to  four  hours.  This  seems  to 
auicsthetize  the  irritated  extremities  of  the  nerves. 

In  irritable  bladder  from  cerebral  or  spinal  disease, 
bromidi'  »)f  potassium,  with  or  without  chloral  hydrate, 
is  an  excellent  remedy.  Here,  however,  it  is  the  prinuiry 
lesion  in  the  brain  or  spinal  cord  with  which  we  liave  to 
contend.  When  there  are  diseiuses  of  the  urethra  or  of 
the  rectum  they  must  be  removed  when  possil)le.  For 
the  immediate  relief  of  irritation  resulting  from  rectal 
diseases  the  most  prompt  and  efficient  remedy  is  a  sup- 
pository containing  from  one-quarter  to  one-ludf  grain 
each  of  morphine  and  cocaine  and  from  three  to  live 
grains  of  hyoscyamus. 

In  the  irritable  bladder  of  gouty  patients  I  have  often 
found  the  most  permanent  relief  from  a  combination  of 
carbonate  of  magnesium,  powdered  rhubarb,  and  col- 
chicum,  as  follows : 

B    MuijiU'.-ii  curb.  (Heiiry'sl, 
Puiv.  rhi'i  (Turk.).  '"'  3'''> 
Vini  cok'liici,  giii; 
Syr.  luiraiitii  corticis,  Ji; 
Aqu:e  menthio  pipuritaj  iid  %  iv.— M. 
Sjg._2  ii  every  two  or  three  liours. 
m 


fflT 


178 


DISKASHS  OF  THE   UnADDNJi. 


This  is  to  III-  «M)iitiinu'(l  until  it  oiu-ratt's  freely  on  the 
bowt'lH,  when  the  irritiitioii  usuiiUy  suhsith's,  jmrtly  iVoni 
the  eliemieal  chimi^e  in  the  urine  prodiieeM  !'y  the  iilkiili, 
but  prohiihly  in  still  ^'reatiT  dej^ree  from  the  relief  atfoided 
till'  portal  eireulation.  1  must  not  omit  to  mention  that  wo 
often  "-et  exeellent  ri'sults  in  this  irritable  eomlition  of  the 
bhuhler  from  very  small  doses  of  bulsam  of  copaiba. 

When  it  is  evident  that  the  bypera'sthesia  of  the  blad- 
der depi'iids  upon  some  eoiii^i'sted  condition  of  the  Wvvv, 
the  exhibition  of  any  of  the  above-named  sedatives  must 
be  preceded  or  accompanied  by  such  cathartics  us  will 
thoroughly  unloatl  the  portal  eireulation.  »Saline  eatbar- 
ties  may  be  used  for  this  purpose,  or  the  magnesia  mix- 
ture already  mentioned. 

In  the  dietetic  management  of  diseases  of  the  bladder 
we  t-ainiot  exercise  too  nuich  care. 

The  avoidance  of  nitrogenous  foods  in  ii-ritable  bladder 
and  cystitis  must  be  strictly  enforced. 

Tlie  articles  of  diet  best  adapted  to  these  conditions  are 
milk,  bread,  and  rice.  Those  to  1)C  avoided  particularly 
are  nitrogenous  foods,  and  very  acid  fruits,  unless  the 
iirine  be  alkaline,  when  the  latter  are  often  beneticial. 

The  same  may  be  said  of  the  mineral  acids. 


CHAPTER  IV. 

ANAESTHESIA   (ATONY). 

Anesthesia  is  an  affection  of  the  sensory  nerves  of 
the  bladder,  consisting  in  an  entire  loss  of  nervous  sensa- 
tion. 

Etiolooy.— This  condition  is  due  in  most  cases  to  dis- 


It. 

I's  IVc'cly  <»ii  tlio 
(k'H,  \\MX\y  tVoiii 
■d  !iy  till'  alkiili, 
u'  ri'licfatl'ni'dcd 
iiit'iitiDii  that  wu 
condition  of  tlio 
of  copaiba. 
I'sia  of  tlu'  Itlad- 
ion  of  the  livi'i", 
1  sedatives  must 
itliartii's  us  will 
Maline  catliar- 
!  magnesia  niix- 

>8  of  tho  bladder 

irritablo  bladder 

se  conditions  are 
ided  particularly 
I'uits,  unless  the 
en  boneticial. 
ncids. 


AX.KSTIIHSIA. 


17!> 


insory  nerves  of 
of  nervous  senaa- 

most  cases  to  dis- 


ease of  the  spine  or  (.f  tlu-  brain,  eausintr,  as  il  were,  a 
paresis  of  the  sensory  nerves  of  the  bladder.  Aside  from 
ciises  in  which  it  is  due  to  diseases  of  the  spine  nv  of  the 
l,iain,  we  shall  probaiily  si^hluiii  meet  with  anu'sthesia  of 
the  bladder  except  from  pressure  on  the  orijan  durintr  par- 
turition or  occasionally  followiiii;  ovi'r-distention. 

Ten  or  fifteen  years  a,t>o,  when  1  conducted  a  laru'e  ob- 
stetric practice,  I'for  a  time  adnuiiisti'rcd  chl(»ral  hydnite 
ill  the  first  sta«,'c  of  labor,  to  (piiet  primary  pain  and  lacili- 
tate  dilatation  of  the  os;  and  in  a  lars>v  number  of  these 
cases  I  was  oblip'd  to  use  a  catheter  on  ac<'ount  of  ames- 
thesia  of  the  bladder.  I  availed  myself  of  this  action  of 
chloral  in  treating;  hypenesthesia  of  the  bladder. 

Symi'Toms.— Fn  this  condition  the  presence  of  urine  in 
the  bladder  fails  to  produce  the  usual  sensation  of  fulness 
of  the  oi\u:an.     The  bladder  will  bei-ome  distended  and  yet 
the  patie'i^it  have  no  desire  to  empty  it  of  its  contents,  and 
it  is  not  until  the  distention  becomes  very  great  that  he 
has  any  sensation  of  its  fulness.     The  bladder  will  often 
overflow  of  itself  when,  in  the  absence  of  pain,  even  the 
phvsiciaii  may  think  there  is  no  possibility  of  the  ori-an's 
bciii<,'  full  of  urine.     I  have  one  patient  who,  though  he 
has  no  well-marked  disease  of  the  spine,  has,  tievertheless, 
ana'sthesia  of  the  bladder,     lie  is  a  very  methodical  man, 
who  never  trusts  to  his  memory,  but  consults  his  memo- 
randum-book for  all  engagements.     To  insure  the  proper 
evacuation  of  his  Idadder,  I  have  had  him  enter  in  his 
memorandum-book    against    certain    liours,    "  fJrii'ritc" 
This  entirely  precludes  the  possibility  of  over-disteiition. 
Treatment. — The  proper  treatment  of  these  cases  of 
ana'sthesia  is  a  matter  of  very  great  importance,  as  paralysis 
of  the  bladder,  as  well  as  inflammation,  is  often  the  result 
of  failure  to  properly  evacuate  the  organ  in  this  condition. 
Inflammation  does  not  so  fretpiently  result  from  paralysis 


f 


ISO 


i)isi:.ts/:s  o/'  Tin:  iir,.\i>i>i:n. 


and  aiiu'silicsiii  as  li.riiici  Iv,  nii  ar.uiint  of  tho  gmit  iiii- 
pnivciiiciit  ill  catlii'lt  rs. 

Tlic  intlicaliuii  for  tivatiiH'iit  so  far  an  the  ItlacMt-r  is 
t'ltiicfnuti  ill  aiia'sllicsia  wiuif  tin  if  is  also  paralysis  is  to 
I'vacuatc  tlic  liladtlcr  at  ri-uiilar  aii<l  tint  too  ion-;'  iiitnvalrt 
witli  a  suit  and  alisdliitfly  «l<iiii  catiict.T. 

Whrii  you  iiistriut  liu"  |iati(iit  or  luirsc  in  tlic  use  of 
tln'  soft  f;itlH'ti-r,  iriw  tlio  most  carcfiil  dirfctioiis  to  secure 
its  cliaiiliiii'ss,  it  is  not  sutlicicnt  iiuicly  to  wasli  tlio 
catluli'r  ill  watt'r;  you  luiisl  sec  t(.  it  that  it  is  placed  in 
ail  uiitisi']>tic  solution  until  used  auaiii.  or  at  least  for  a 
KutUcii'iit  time  to  insure  disinfection.  Very  often,  in  an- 
a-sthesia,  wlieii  the  hladder  is  emptied  it  contracts  (luickly 
and  normally,  sliowinu;  no  implication  whatever  <»f  tlio 
motor  nerves.  This  is  esi)ecially  true  of  many  of  the  cases 
of  so-calii.l  paralysis  of  the  bladder  after  parturition.  I 
am  Hatistied  that  in  the  majority  of  these  cases  w»>  have  to 
deal  simply  with  an  aiacstlu'sia;  hut  the  hladder  is  evacu- 
ated prohJihly  only  twice  every  twenty-four  hours  hy  the 
physician,  and  lu'iice  hecoiiies  j^reatly  distended,  which 
jtroduces  partial  paralysis.  This  may  continue  (or  weeks; 
while  if  the  cathett'r  had  Ix'eii  used  from  four  to  six  times 
in  the  twenty-four  hours  the-hhulder  would  liave  recoveri'd 
its  normal  sensation  in  a  few  days  and  shown  no  disposi- 
tion whatever  I :)  paralysis. 


,;, 


i:i{. 


cySTOSfASMIS. 


181 


I  i»f  tlif  giH'iit  ini- 

aH  tlic  lilii(l<lrr  is 
Uso  iiiiriilvsis  is  to 
too  long  ininviilrt 

• 

iirsc  ill  tin'  use  of 
ircctioiis  to  scciuv 
■icly  to  wasli  till' 
liiit  it  is  i>lii<'»'(l  ill 
,  or  at  least  lor  a 
Very  oiK'ii,  in  an- 
I'oiitracts  ([nickly 
whatever  of  tlio 
'many  of  tlio  casos 
rr  i»arfurition.  I 
0  casts  \v»'  have!  to 
'  Madder  is  evaeii- 
foiir  hours  hy  the 
distended,  whieh 
)ntinue  lor  weeks; 

II  four  to  six  times 
iild  have  recoveri'd 

tjliowu  no  dispoai- 


(11  APTKK  V. 

rY^TOSl'ASMlS  (Vf.SIC.M.  SIV\S.M-Sf ASM  ol-  TlIK  lU.AI.I.CIl- 
,.VST.)S1'ASM— SPASMIS  VKSIC.K— IsamUIA  SI- NSMulurA  — 
CYSTOSPASTICI'S— IIVI'KIICINKSIS). 

In  evsto.niismus  there  is  a  <listurhan.e  of  l.otli  tlw  sen- 
s..rvand  the  motor  ne.v.s  of  the  hla.hler ;  that  irt,  there 
is  spasmodie  eontraetion  of  the  hladder,  with  pain. 

l.Vr,o,,()(iv.— Cvstosi-asmiis  is  oeeasioiially  dein'iideiit  on 
disease  (.f  th*"  hVaiii  or  ..f  the  spinal  eord,  hut  is  usually 
,..msed  hy  loreign  h.xlies  in  the  hladder  or  hy  inllammatioii 
of  the  oVtran,  or  is  rellex  from  some  reetal  disturhan.r. 
The  most  fre.iueiit  eaiise  is  st..ne.     Amte  cystitis,  ulieii 
the  muscular  stru.'ture  of  tJie  wall  is  involved,  is  usually 
,,,„,npanied  hy  severe  spasms  and  tenesmus.     Strn-turc 
■of  the  urethra,  or  urethritis,  will  pr.xlii.'e  it  only  when  the 
neck  of  till-  hladder  is  involved.     In  highly  nervous  patients 
the  introduction  of  a  catheter  will  provoke  a  spasm  i.t  the 
sphincter  vesi.'.e,  and  in  hysterical  patients  this  condition 
may  ho  the  result  solely  of  the  general  nervous  condition, 
frritatiou  of  the  uterus,  fissures  and  a  hemorrh<.idal  con- 
dition of  the  rectum,  are  sometimes  responsihle  tor  these 
attacks.    ()ne  of  the  worst  cases  I  ever  atteiidi'd  was  caused 
bv  a  pericvstitis,  whii-h,  however,  in  this  instaiiee  was  the 
result  of  a  goiiorrh.eal  cystitis,  the  eystosi.asnius  or  cyst..- 
spastic  condition  not  manifesting  itself  until  the  inilamma- 
tion  had  spread  hevoiid  the  walls  of  the  hhuhler. 

^„„.TOMS.— There  is  gi-nerally  great  intolerance  ot  the 
],ladder  to  the  urine,  with  severe  spasms  atten.lmg  the 
etlbrts  at  micturition,  and  teiu'smus  that  is  as  painl.il  as 
the  tenesmus  of  dysentery.  The  hlad.k'r  contracts  u.to  a 
hard  hall.     When  the  spasm  is  the  result  of  urethritis  or 

10 


■T'* 


i 


182 


jusr\tsi:s  of  tiik  nt.Annr.K. 


..I 


••yHtitis,  till  re  will  III'  livcr.  When  <ini!<iil  l»y  ntotu-,  it  i-t 
iKif  likely  to  lie  very  Ht'Vi-n'  imloHHcyHtitis  is  |ircH»'iit  Tin  re 
lilt'  lew  tliseiises  tliiit  life  niitfe  (listreftslli^  tliuii  ueiiti'  eyn- 
titis  ae('niii|(imie(|  hy  eystiM|iasiMiM. 

Tin:  M  MKM'. — The  imlieiiliini  is  t<»  allay  the  \esieiil  ini- 
tatioii  li\  reiiiiiviiiji;  tlie  eaiisi-,  if  |i(Wrtil»U'.  Tliis  eaii  usu- 
ally l>e  tluiie  when  stoiic  (»r  I'orci^^n  liodies  are  |iri'se?ii  ill 
the  lihiililer,  or  wlwii  there  is  a  diseased  eoiiditioii  of  the 
reetiiiii,  such  as  lissiirc,  heiiiorrlioids,  ete.  When  it  ae- 
et)iiil»atiies  ueute  ey(*titis  it  may  take  some  time  to  (iiiiet  the 
irritation. 

It  will  he  advisahle  iirst  to  dilute  the  iiriiH"  well,  hy  the 
administration  of  eonsiderahle  (|uantities  of  mineral  water 
or  riee-water,  milk,  or  lluid  I'Xtraet  of  tritieiim  repeiis. 

Hot  sitz-lmths  or  hot  a|>|ilieatioiis  across  the  lower  part 
of  tln'iihdomeii,  with  rectal  suiipositoriesof  morphine,  will 
fru(|ucntly  (piiet  tlie  hladder  for  a  lew  hours. 

Tincture  of  hyoscyamus  with  morphine  and  irotrmaiin's 
uiiodyne  or  spirit  of  nitrous  ether,  l»y  the  mouth,  are  some- 
times successful  in  allayini;  the  irritation.  Occasionally, 
ill  spite  of  lu'at,  sitz-haths,  sedatives,  or  suppositories,  we 
ureohlisieil  to  resort  to  tilliiii;  tlu- hladder  with  warm  water. 
Hot  rectal  enemata  arc  useful  in  many  cases.  (Jreat  heiie- 
tit  ofton  results  from  chloral  hydrati'  in  doses  of  from  ti-n 
to  fifteen  tfrains  t'very  two  to  four  hours.  In  the  spasms 
occurrin<^  from  cerciiral  or  spinal  initatioii,  relief  is 
jfeiierally  obtained  fi(jm  the  udministratiun  of  bromide 
and  chloral  combined. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


/. 


1.0 


I.I 


1.25 


^  '^    1122 


L. 

*-     1. 
Itawu. 


2.0 


18 


U    11.6 


7 


Photographic 

Sciences 
Corporation 


V 


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u;^V^?i'-?a^?^*i-^-'^as^K«S!^'»^:esii^A^!S^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  IVIicroreproductions  /  Institut  Canadian  de  microreproductions  historiques 


vV 


■mwmiSZiSmm^^msm^m^m^/^sm^;.. 


CiSTOl'LECIi- 


ls:i 


(-llArTKK     VI. 
rvsToru^nA  (.■auai.vsis  ok  tm.  m,A..nKU-Ar.NKsis-vKsi- 

CAI,    1'ALSY). 

T.n.  is  a  imivlv  motor  n.nrosis,  :nwK  US  a  rnl-   .1.1-n.ls 

t'     ,,U;.    (>v...-.r.st.ntionoftlu.Ma.M..r,n,.l.,->..'ntl 
,.:...us..of.vt.ntion,willU.av.tl .-.an  ,,avab-.M. 

L.nt  or  a.-ut.  intlan.uation  of  ,!>.  ,rostar.  j^Uvna.     L  t 
'  ,K.at  it  is  not  tlu-  .-a-.s.  of  th.  n...ut,..n  that  ,>ro,  n.H">  tlu 
;   ;tlj.ntth.M.v....ist..i<.n.    l'n.ssu...M^ 

,v  tlK-  .'hiLrs  lu'a.l  anrin-  partunt.on  xv.ll  soim'tiuu".  U.ut 
hJ     aLMna,avaly.c.a<-onaition:la.n.l.ow,.^^^ 

,.,  ,,..,.  ,„  a,Kvstlu.sia  or  u  ..t.ntion  ..t  nnn.  n.  a 
.w.Uin^-  of  tlu-  urethra,  .ans.d  hv  tlu-  ,a-.ssuro  ot  tlu-  lu  ad, 
ntlRT  than  a  true  paralysis  of  tlu-  l.la.UUr. 

F    tv  a...-u.ration  a.ul  atropl.y  <.f  tho  inu^nlar  walls 
of  tiliaaaaor  .onstitnto  a  .auso  of  paralyse  of  th.  organ 
•nl.onu.n.     In  fever,  of  a  s.v.ro  typ.  tlu.  power  ot 
,u.rv.-.on<l.u-tion  is  often  either  lost  or  unpjurea. 
'"s,„,,.,MS.-\Ve  often  tina  a  lar.n-  roun.l  t.nnor  in  the 
U,;   ,.  p  rt  of  the  ahaomen,  risinjr  up  hehina  the  p,a>es,  n«n- 
!;;;;  :.!ntral  ana  paintnl,  when  the  aistentu.n  ,s  the  result 
of  ineehanieal  ret»'ntion. 

It  is  <.ften  nnae..onM.aniea  hy  pain  when  the  resnlt  c  f  a 

central  nerve  lesio.i,  ..n.l,  thou-h  the  viscus  may  he  ^.-reatl^ 

an.    lea,  the  patient  ana  son.etimes  even  the  physunm 

;^-  he  d^ceivc^l  a.  to  the  natnre  of  the  tn,n.>r,  ow.n,   o 

L  laet  that  in  many  of  these  ease,  there  ts  a  constant  a.  ,1  - 

in.  of  urine,  while  in  son.e  of  them,  in  eonse<iuenee  ot 


'iss4cs«=i-i®^ssm-'ss«*' 


isl 


nisK.isrs  III'  Tin:  i'.i..\nni:ii. 


tlir  ;iliii(p-t  ((iiiiiilcli'  |i;i:'alysis  nC  the  s|iliiiiit(i'  iiiuscli's,  the 
Itliulilci'  i-  iini  ovci-ilistfinlcil.  the  (li>i(iitii>ii  luiiiL;'  r*  Ticvi-d 
liy  the  ovirtldw.  Asiilc  t'nnii  tlic  s\ miitoins  (•(iiiliiUMl  to 
tlic  liliiildcr,  tlnTc  iifr  Mt'icii  otlicr  f(Hiiiilic;iti(His  nsiiltiiiLr 
fViiiii  (Ir.  I'llorts  1)11  till  |i;irt  of  till'  patient  to  (.■  iqity  a  jiafa- 
ly/.rd  or  |iaitially-|iaialy/.i'(l  lilailijff. 

llfiiiorrlioiils  and  |ii'ola[tsiis  of  tlic  I'frtiiiu  aic  tin'  most 
coiiiiiioii  ot' till- distris>iii!X  roiiditioib.  that  ai'isi';  l.iit  1  liavf 
seen  tlic  constant  stfaininu"  |proi|ii(c  liroiicliial  and  cinpliv- 
scinatous  conditions,  and  acute  cystitis  ai'isi'  iVom  the  <lc- 
(•oni|M)sition  ol'  the  fetaiiied  mine. 

Th i:\T.M i:nt. —  in  the  treatment  ot'  pai-alysis  de|ien(h-iit 
on  sjiinal  of  cei-el>t'al  disease  the  most  tliat  can  he  done  i;^ 
to  use  the  soft  catheter  at  re;,nihir  intervals.  Strychniiu', 
electricity,  'riction.  eantliarides,  are  ail  likely  to  in-ovo 
useless  nidess  tin'  central  lesion  he  imiiroved  hv  the  retne- 
«lii's  em|»loyed.  In  paralysis  cansed  hy  over-distention  of 
tlu'  oiyan  resnltimr  tVom  sonu'  mechanical  ohstriiction, 
the  Madder  is  likely  soon  to  recovei-  it'  the  ohstrnctioii  is 
removed  and  the  urine  is  proju'i'ly  evacnated  at  reti'ular 
intervals.  In  the  paralysis  followinij,-  parturition  the 
rapidity  of  the  recovery  will  depend  larirely  n|>on  whether 
or  not  the  nriiie  is  drawn  t'roni  the  hiailder  sntlicientlv 
often.  It  is  the  haiiit  of  many  medical  men.  in  these 
circiiinstances,  to  use  the  catlu'tcr  oidy  twice  a  day,  thus 
allowiiiLj  tin-  hladder  to  he  constantly  distended,  -o  that 
perhaps  Weeks  may  elapse  hefore  it  retiiinstoits  normal 
condition;  while,  if  the  nrine  wcri'  drawn  more  fre- 
(pie.itly,  <»ver-<listention  Ih'Iiil;:  provided  apiiiist,  the  con- 
dition would  disappear  in  a  few  days. 

This  precaution  of  tV<'(iuently  emptyinij'  the  hladder  i.s 
rei|uisit»'  in  any  other  ease  of  paralysis  eausi'd  hy  over- 
distention. 

.Mo>t  ot'  these  eases  recover  without  the  aid  of  niediea- 


VESICA  I.   CM.  en. I. 


IS;-) 


■r  iiniscli's,  the 
lirilli;-  rrlic\  I'd 
lis  (■uiiliiii'il  to 
ioiis  rtsiiltiiiiT 
t'lilitv  a  |piira- 

1  ai'c  till'  llinst 
si' ;  liiit  1  liavr 
ill  and  ciiijiliy- 
i'  liDiii  tlic  de- 
sis  di|irlldi'llt 
•an  l>r  di)ni'  "h 
Stryrlniiiie, 
<rly    to    |H("V(.' 

I  l»y  till'  rcnu'- 
-distrutinii  of 
1  olistnictidii, 
obstnu'tioii  is 
U'd  at  rrii'ular 
I'luritiiiii  the 
ii]inn  wliether 
•r  ^utlil•il•lltl_v 
nen.  in  these 
re  a  day,  thus 
nded.  -I)  that 
to  its  normal 
k'li  more  tVe- 
liiist,  the  t'oii- 

lie  liladder  is 
ised  liy  over- 
id  of  inedica- 


lioii.      When   it   heeomes  necessary,  eleitriiily.   niassaL-'e. 
and  stryelinine  aie  the  lie>t  remedies. 

i  tVeiinentlv  u'ive  a  eomliinatioii  of  tincture  of  nnx 
Vomica  and  spirit  ot'  nitmns  eti  r,  and  lind  it  answers  an 
admirahle  iinriio>e.  Here  let  me  aiTiiin  '"iH  attention  to 
tlie  imiH.i'iaiice  of  keepin;.''  catheters  ah^olntely  clean, 
n>ini:'  f"r  that  |niriiose  salt,  carholized,  or  iiichloride 
solution. 


ClIAPTKU    VII. 

VKSIC.M.    ( M.ril.I    (cYSTn-MTIIIASIs). 

l/,-,,,i,n(;v. — Wiiat  has  Iieen  already  said  of  the  etiolotry 
of  renal  calculi  api'lies  eiiually  to  vesical  calculi  While 
air*',  sex,  and  location  as  etiolouical  factors  play  ahout  tlio 
sanu'  part  hen',  catarrhal  iidlammations  are  responsilde 
for  more  vesical  than  renal  calculi.  A  calculus  in  the 
]K'lvis  of  ihe  kidney  will  undoulitedly  produce  pyelitis, 
and  a  calculus  in  the  liladder  almost  invariaidy  proiluces 
cystitis;  hut  in  a  laruH'  numlier  of  cases  of  stone  the 
catarrh  of  the  Madder  precedes  the  stone  and  is  resi.oii- 
sihle  i\n-  it.  There  may  he  special  stotie-makinir  catarrhs, 
its  A'ickle  suu-iri'sts.  As  to  tile  nature  of  the  vesical 
calculi,  they  corres[iond  with  what  we  have  already  seen 
in  renal  calculi. 

Sv.Mi'Tii.Ms. — Stone  in  the  bladder  ,!.cenerally  indicates 
its  existence  hy  one  or  niori'  of  the  followiiiir  symptoms: 
irritation  of  the  Madder,  cystitis,  cystorrluiiria,  and  pain 
ill  the  hladder,  followins;  tlu'  course  of  the  urethra  and 
often  referred  to  the  head  of  the  penis.  (Vstospasmus  is 
occasionally  present.  The  patient  will  sometimes  find 
that  in  the  act  of  urinatin.iX  the  sti-cani  is  suddenly  cut 

10* 


-.*is^^88i«»#»«s^«««rf»«aB^^ 


]Si\ 


Disr.AsHs  iti   Ti'i-:  iii..\i>i>i:ii. 


(tir  lict'urc  the  liliiddt  r  is  ciiiiilicil,  |in.li;ilil,v  ciiuscd  \<\  llic 
stuiii-  iiilliiiL,''  iiijii'""^'  'Ik'  outlet  tit' till'  IthidtltT.  'I'lif  Kiily 
tlmi'iMiiilily  !•( Tiiililf  iiicaiis  of  (li:iL''nii>is,  liowcvi'i'.  i>  thr 
(Icliliilistl'iltinll  of  stiilU'  in  tlu'  l>l;i(I(|c|-  li_V  lucjms  III'  tlu' 
stniud.  wliirli  slioiild  iilwiiys  In-  used  in  siisjiirii ms  ciiscs. 
Win  II  tlif  stone  is  siifc'ilatcd.  it  is  dillinilt  to  discover 
its  |iresence  I'Veii  witli  llie  soiniil.  When  tiie  Miidder  is 
initiilde  and  iiaiiil'iil.  an<l  a  satisl'aetopv  exainiiiation  ean- 
iiot  lie  niaile  liy  means  ol'  the  local  use  ot'  coi'aine,  it  is 
hettei- to  ana'stheti/.e  the  [latieiit  and  detenniiie  ahsoliitely 
whether  or  not  stone  is  |iresent  .  nor  must  we  I'ori^-ct  that, 
inasmuch  as  cystitis  is  iVeijiientlv  the  cause  ol'  stoiie.  it  is 
neeessarv  where  a  cystitis  is  oi'  loiii!,'  duration  to  t-xaniiue 
tile  hladder  carefully  from  time  to  time,  say  at  least  ever_\ 
thi'ee  months.  I  have  known  a  patient  >iitrerinu'  troni 
cystitis  to  have  lieen  caret'iiily  examineil  t'or  stone  with 
iu'<rati\e  results,  and  yet  al'ter  some  months,  he  havinir 
lias>ed  in  the  mean  time  into  the  hands  of  aiiotlu'r  phy- 
sician  or  surireon.  an  »'.\amiuation  revealed  the  |>risenee 
of  a  >tono,  when  hoth  surii'eon  and  pjitiiMit  si-emi'd  per- 
t'ectly  salistieil  that  tlu'  t'oriiier  examiner  was  incoiiiiietent. 
It  never  oecurri'd  to  them  that  tlu'  stone  had  formed  since 
tile  previous  examinafitui. 

Ti!i;\t.mi:nt. — The  removal  of  vesical  calculi  lu'louii's  to 
the  domain  ot'  surirery,  unless  the  physician  for  some  cases 
sees  tit  to  try  what  is  usually  known  as  Koherts's  solvent 
treatment,  w  hich  consists  in  both  the  administration  ot", 
ami  hx'al  treatment  !iy,  nieilicines  calculated  to  ilissolve 
the  stiuie.  We  have  st'eii  in  the  chapter  on  reinil  calculi 
tliat  the  oxalate-of-limo  or  mullH'rry  stone  resists  all 
sohiiits. 


VYSTitltnilMilA. 


1S7 


<1I!1S('(1    |i_\     lilt' 

IT.      'I'lif  Miily 

(i\\f\rr.  i>  till' 

llU'illls   nl'  till' 

s|iiciiins  cascr*. 
lit  to  discover 
the  Madilff  is 
iiiiiiiiition  i-:iii- 
t'  cociiiiii',  it  is 
line  iilisolutcly 
,v('  l'oi-i:-(t  that, 
'  ol'  stoiic,  it  is 
ioii  to  I'xaiiiino 
/  at  least  cvcrv 
>iill('i'iiiu'  iVoiii 
tor  stoiif  with 
tlis,  \\v  haviiii!; 
r  aiiotlu'r  I'hy- 
1  tlu'  pri'sciicL' 

it    Sl'l'llUil    \ivY' 

IS  iiir<>iiili*.'t(.'iit. 

i(!  t'ol'llK'd  siiici! 

culi  holoiiii's  to 

I  lor  soiiit'  casoH 
•In'rts's  solvi'iit 
iiinistratioii  ot", 
tt.'(l  t()  dissolve 

II  rriial  rak-nli 
oiiL'    resists    all 


ClIAl'TKK     V  1  II. 

,'VSTOUlMl\.ilA     (VKSWM.     „  ,,M  AT.  IM  \-lIKM<>UUn  A.IK     FlU-M 

Tin;  iti,.\iM>i:ii)- 

ETi..i.n,.v.— Th.'iv  aiv  various  .auses  which  -ivc  rise  to 
hciiioi-rhaLC''  t'l'oiii  the  hlaildcr. 

l„im-U's,oitlu'r  th.iii  l.lowsor  iVoiii  pcnctratiii- w.miids, 
are  ,vs,.onsihU'  for  s..nu'  rases.  ( )ceasioMally  such  diseases 
us  ..urimra  |iaMnoi-rha-i.">  and  s...rhntiis  produce  it. 

StoH..  ill  the  hla.lder  is  a  fre.iue.it  .'ause,  as  is  ais.. 
ul.^erati.MK  siiuple,  syiihiliti.-,  ..r  tuhereular. 

(irowths  ill  the  hla.hler,  inali-uaiit  c.r  heiii-n,  seld.un 
fiil  to  -nve  fise  to  int*'reurrent  heiuorrha.iTi',  eaiicer  and 
,he  luucus  i.olyp  heiii-  i.u.st   fre.iueiitly  atteiuh'.l  hy  this 

sVlllWtolU.  ,.     ,  ^       ,. 

■  Acute  evslitis  n..w  an.l  then  -ives  a  sh.ixht  aiu..unt  ..t 
fresh  iv.l  "hl<>"<l  i"  tlu.  urine,  while  a  passive  eouirestioii 
<,r  the  vesi.-al  veins  from  cancer,  or  cirrhosis  of  the  liver 
,,,  otlu'r  ohstruetion  to  the  p.-rtal  eiirulati.ui,  must  he  re- 
niemhere.!  as  a  i...ssil.le  source.  We  have  alrea.l^-  state.l 
in  the  etiolo-v  of  luematuria  that  parasites  tuay  l.xl-c  in 
tlu'  mueous  meml)rane  of  the  hlad.ler  an.l  produee  hem- 

'  Sv.MPTO.MS.— For  the  differential  dia-rnosis  from  hemor- 
rhatre  derived  from  other  p.)rtioiis  of  the  urinary  tract, 
see  the  chapter  on  hiematuria. 

Tui:\TMKNT.— The  ruh's  as  reirards  rest  an.l  diet,  wliieh 
we  have  already  i?iven  in  the  chapter  on  luvmaturia  apply 
e.iually  whethJr  the  hemorrha.ire  comes  from  the  hhuhU'r 
or  from  the  kidney,  ami  the  same  may  be  said  ot  the 
udministrath.n  of  medicines.  In  ad.lition,  however,  we 
have  the  advantage  of  local  ui.plicatiuu  of  remedies. 


,-JS»aS^3^ 


««^aE03KSSpP!3We^J'iSW*«A*««*''*-iia^ 


■msa- 


\ 


wm 


ls,s 


/)/.sA'.(.v/.;\  1,1    Tin:  /.7,.i />/)/./,•. 


Wlicll  llic  lHIil(.M-|i;iL;-..is(.l.stilliltr,  wllctlicrrn.lll  llIciTM- 
•'""  '"■  ''""I  "l''  |'I'*'>>'M'<-  <'ril.'<.|.li|Sllls,  W,.  |i,;i_V  Wiisli  ..lit 
tl.c    l.|;i,|.|,.r    with    aMiill-rnI     IcfiullS    lll„I     tlllls's..||M'tillU.S 

will  sii,T..,.,|  in  iirnstiiiu-  tlir  liciii..iTli;ii;-,.  wlicii  svstL'ini(! 
ninr.lics  liiivc  I'iiil...!.  of  lli,.  iistriiii.'-.Mit  Wiisli.s.  tlios.-  of 
,ir;illic  ji.i.i  iiiiil  tiiiiiii.'  iiri.l  :ir,.  d,,.  siiH.st  and  iiK.st  .•Hi. •lent. 
(Uliri-  iistrin.ircnls  wli.n  |.r.)|.,.Hv  dilnti'd  cjui  l.c  used 
wilhuiii  .l.tiiniciii  t..  til..  I.lad.l..!-.  Wl,,.,!  thr  li.ni..n'li!itr(! 
•I'T'i"!-^  >i|.<iM  ii  n.w  irn.wtli,  <.r  ii|„.ii  .-al.'iiliis,  ilic  trcat- 
iiH'iil  iimst  \)v  siiruical. 


<'I1AI'TKH    rx. 

CYSTITIS— ACtTi;,    sriiACITK,    AM)    rilRONIC. 

AVk  dfsii.ni:!!.'  f  li."  iiiflamiiiatioiis  of  f  h..  Maddn-  as  acute, 
Htiliaciii.',  .(f  .'lir.ini.'  cystitis. 

Ivn(»l,u.;v    cK    ACITIO    AM)    SlIiAcrTr,     CvsTITtS.  — .|//r.— 

(>titis  oc.Mirs  at  all  a,i;cs.  Fii  cjiildivii,  however,  tlio 
disease  is  usually  of  a  mild,  suhaciite  character,  except 
wh.'iv  produced  l.y  vesi.'al  calculi  or  followin.t;  the  acute 
intectious  diseases. 

,SV.,-._rn  childhood  l.otji  sexes  are  e(iual]y  subject  to 
cystitis.  In  early  adult  life  youn.i;  men  sutfer  oftener 
thau  youui;  women,  l.ecause  of  their  more  tVe(iuent 
attacks  of  ironorrliu'a  au.l  lial)ili(y  to  stricture. 

Women  durin<r  the  ch;id-I)earinir  period  are  verv  sub- 
.ject^  to  catarrh  of  the  bladder,  .)win<r  to  the  vesical  hyper- 
.•emia  caused  by  iireijnancy  and  to  the  injuries  incurred 
by  tlie  blad.ler  and  neii(hb.)rini(  tissues  du'rin«,'  deliverv. 

Tn  old  a-re,  say  after  sixty,  men  are  far  more  subject,  to 
<-ystitis  than  women,  from  their  tendency  to  prostatic 
disease. 


1 


cysTiris. 


isi» 


I'l'  iVdlii  IlIciTll- 
liliiv  Uiisli  out 

HIS  soiiH'tiiiu'K 
vlu'ii  systemic 

IsllCS,  tlldSC  ot" 

iiKtst  I'tlicitnt. 

cim    l)c    usod 

I'  lif'iiori'luiii'c 

iliis,  tlic   tl-fllt- 


RONIC. 

•  Idcr  iis  iK'tito, 

riTis. — Af/r. — 
llOWt'VlT,  tlio 

^actor,  oxci'pt 
iii.tr  the  iic'uto 

lly  siihjc'ct  to 

■iifU'r  ofti'iRT 

ore    tViM^iK'Ut 

re. 

aro  vi'rv  sub- 

■fsicivl   llVplT- 

rios  incurred 
liC  delivery, 
re  subject  to 
to  prostatic 


Tiijuries.  direct  blows.  Tails,  ..r  peMetratiii-  wouixls  iiiv 
eticluuical  taet(.rs,  as  well  as  vesical  calculi  ..r  oilier 
foreiii'll  b.Mlies  ill  tbe  bladder.  (Vslilis  is  ofK'U  caused 
Hccondarily  by  invasions  of  the  bhidder  from  a  urethritis, 
specitic  (u"  otlierwise,  diseases  of  tbe  kidneys  or  ureters, 
peritonitis,  pelvic  cidlulitis,  and  inilauimat  ions  of  tbe  pi'lvie 

orirans  or  tbe  prostate  .irland.  It  not  infre([Uently  bappeiis 
tbat  i'-om  some  obstruction  iuterferinn'  N^-'b  tbe  complete 
emptying-  (.f  tbe  bladder,  as  in  i'nlar<i'c<l  prostate,  pbiniosis, 
paralysis,  etc.,  decomitosition  of  tlu'  urine  takes  place  and 
pnxluces  intlamniation. 

Another  source  of  cystitis,  which  fortunately  is  not  so 
tVeipient  as  formerly,  is  the  use  of  unclean  catheters;  and 
cystitis  occiisionally  residts  from  the  mere  passinji;  of  a 
sound  or  •.  catheter.  Any  of  the  acute  infi'ctious  dis- 
eases,  as  also  pya-mia,  nniy  be  accompanied  or  f.dlowed 
by  cvstitis,  with  or  without  intlamniation  of  the  kidneys. 
Oeeasionally  we  encounter  a  diphtheritic  cystitis,  which 
is  usually  secondary,  with  or  without  ityelitis. 

In  deidiuti;  with  intlamniation  of  the  blacbUr  we  must 
never  forii-i't  that  ill-defined  etiolo,u;ical  factor,  catchini? 
^.(,ld,— especially  tretting  the  feet  wet;  and  if  pi-ri'bance 
wt"  iind  a  case  that  we  can  truce  to  no  known  cause,  we 
must  satisty  onr  i)atient"s  c\iriosity,  if  not  our  own  intelli- 
ireiice,  by  designating  it  as  of  idiopathic  origin.  \  bayo 
more  than  once  been  assured  by  pliysicians  that  a  certain 
disease  was  idiopathic,  tbe  dictum  beinijc  uttered  with  such 
an  air  of  wisdom  and  dit^nity  tbat  I  could  not  but  believe 
that  the  word  conveyed  to  them  some  idea  of  definite 
etioloirical  information.  The  word  may  be  eonvenieiit 
for  lazy  physicians,  l»ut  it  is  the  cause  of  inealculable 
mischief. 

Men  with  gouty  diathesis  have  a  greater  tendency  than 
others  to   cystitis;    and    the    mucous    nieiiibraiie   of  the 


.;539:«'3'3i!»*.-=S»!'^^'^-'^:?*^^^'6*!E=^53OT'^^ 


1!»0 


Disn.tsKs  or  Tin:  ni.MthiiH. 


I>liiili|i'i',  liki'  iiiiv  otiii  r  iiMit'oiH  iiii'iiiltniiii',  muv  iiithiiiic 
iMul  iilccrali'  iliiiiiii;  tin-  course  of  s_\  |.|iilis.  I  Imsc  -rcii 
a  •ystitis  \\\v  oiilv  ii|i|iiirciit  ciiiisc  ul'  u  liirh  wms  |phitii<i»is. 
N'i'W  jji'iiuths  ill  ilic  liliiildcr  trfiu-nillv  |p|(m1iicc  initiiiiMii 
aixl  <'at;it'rli.  The  iiniiiiiiMiis  or  too  lon^-  runtiii'ieil  use 
of  eertaili  liiedi.iins  will  soilietiliies  set  ii|i  ail  iiithiliiliJii- 
tioll  ot'  llie  Maihler,  tliis  iteilii;  es|ieeially  till-  ea>e  with 
tur|ieiitiiie,  eii|.ailia,  ami  eaiitharideK. 

Ivrioi,o»iv  or  CiiitoMc  ("vstitis. —  Va\'\'\  ease  of  rlnonie 
e_\>-titis  is  the  roiilt  of  an  aeiite  cir  u  siihaeiite  altark  ;  liie 
Kultaeiit.'  attack,  liowevef  iiiiM,  may  liiially  ri'siilt  in  a 
aovi'fe  chronic  inlhiiiiniatioii. 

I'atiioi.ikiv. — The  |iathoh>Lry  of  acute  cystitis  (|c|ieiiiis 
npoii  tile  severity  of  the  case  and  n|Min  tlu'  tissues  in\  ul\ cd. 

WhiK' it  is  siiiiiijy  catarrhal,  that  is,  while  the  niiicoMs 
ineiiihfaiu'  alone  is  involvt-d,  there  is  hy|ieiiciiiia  ;  the 
iiieiiilirane  is  red,  relaxed,  and  (i'(leiiiatoiis,  and  it>  suit'acc 
beeonies  denuded  of  its  e|iitheliuiii  and  is  eo\cred  with 

IIIUCMS.       Thel'e    is  a    lit'olilcratioii    ot'  yollHi;    eell-li'rowths. 

the  urine  hein,:;  turhid  and  loailed  with  mucus-  and  |ius- 
(•orpuscles.  Cystitis,  liki'  all  othei'  int!animation>  ot' 
mucous  niemhraiics,  may  t«'i'minate  in  resolution,  ulcefa- 
tioii,  or  chi'onic  int!aniniati(Ui. 

In  an  attack  of  acute  <'ystitis  whieli  involves  the  siiii- 
intu'ons  and  miis<'ukir  coats,  the  whole  wall  ot"  the  hladdcr 
hecoiues  thickiMied,  owiiiij  to  an  e.\iHlati(>n  and  |>rolit'cra- 
tioii  of  cells  that  take  [ilaee  in  the  sultmucous  and  mus- 
cular structures. 

In  clii(riiie  cystitis  the  mucous  m-  nihrane  is  no  Ioniser 
red  and  relaxed,  hut  is  of  ii  i^rayislt  color,  irrcirularly 
thickened,  and  covired  with  a  |iurnlcnt-lookiiiir  secretion 
of  muciis  and  |ius.  The  sidtmiicoiis  and  muscular  struc- 
tures heeonie  nuieli  thickened  and  hy|iertroiihied,  jiai'tly 
from  exudation  and  partly  from  contraction.     Tlu'  urine 


If,  IllilV  llltlilllli- 
is.        I    llllSc   xi'll 

I  ujis  |p|)iiiii>His. 
iilii<'c  initiiiinii 

•  oiiliii'ii'il  lis*' 
i|>  all  iiitlaiiiiiiii- 

tlu-  »iisi'  willi 


(•use  III'  ilndiiic 
iitf  jiltack  ;  till' 
illv   ri'siilt    ill   a 

•ystilis  tl('|K'ii(ls 
issiii's  iii\(ilv»'(l. 
lie  the  iiiilciiiis 
v|K'i'a'iiiia  ;  tlit" 
,  aiitl  it>  siirt'aci' 

is    (■(iNTI'l'd   uitl) 

lu;  ft'il-ii'rnwtlis. 
iiiii'iis-  ami  |iiis- 
laiiiniatiiiiis  of 
iitliitidii.  iilcrra- 

VOIVCS     till'     Sllll- 

I  of  tln'  l)la<l(irr 
I  aii<l  |ii'(>litira- 
U'tiiis  ami   iiiiis- 

iiic  is  iKt  iDiiifcr 
lof,  in'ci^iilarly 
i)kiii<x  S('ci't'tii>ii 
iiiisciihir  stnic- 
miiliii'il,  iiai'tly 
)ii.     Tlu'  uriiK! 


rysTiTis. 


I'M 


in  tui'l.i.l.  nihil  alUaliiir.  ami  sniii.tii.i.  s  ,„iiiii..ma.al.  I  la' 
,„.„,.  ,l„,,„i,,li.'.r.s>.a>.'.llH'lrsslik.'ly  is  it  tot..|n..i,;.t.' 
ivrnwrv.all.l    th.'    IV    IiU.lv  tn  IVMllt    ill    iilr.Tat  i.m, 


HI    I 


,„.,,;„,„;,„■,.  or  sill... lU.M.us  al.s.vss.  ami  t-  |.in.li..'.'  ni..r.' 
.,!•  1..^^  l,vii.'iti-..i.liv  ami  .'uiitra.'tiuii  of  lli.'  I.la.l-l.r. 

SvMnnMs.-Thr    sVlliptollls    of    a.iitr    .'yMilis    .l.iM.ml 
,     ,,„    ,1,.,    ..x,..,it    of    involvriiirnl    of    til.'    Ma.l.l.T-wall. 
Whrn  uiilv  111.'  ninroiis   .iminlmiiu-  is  ii,v..Kv.l.  un  iiiatt.T 
how  a.'.it.''  tlu'  attarU.  tlu-  f.-wr  is  vvi'V  im'o.i^.U'faMr.  tl.o 
t.n.iH'raf,.v  m.t  uft.u  ri-in.tr  ahov.  l.m'^  or  KT.      I  li.'.v 
i.  not   lilo'lvto  1...  aiiy.li>ti.i.I,..r  nitlirr  il.tnm.l,  rliill, 
altl.oii.^h  tlu'ro  arc-  ..ftni   iviu'ivi.t  .Inll.v  srnsiti..ns.     Iii- 
tolrran.'.'  n\'  tlu'    l.la.l.l.T   to  tlir   uiMm-  will    1'"   pn'sHit, 
c.s,K'.'iallv  wlu'ii  walkiiiir,  an.l  tlirn-  will  W  soiim  t,'ii.l.'r- 
nrss  o\vr  tlK'  l.la.M.T  i.l.nv.'  tlu'  pulu's.     Mirtiintimi  h 
tV-'MiU'i.t   an.l  |,aintiil,  111.'  pain  l..in,ir  most  si'V.iv  at  tlm 
.•losi-  of  til.'  .'llWrr  an.l   l.-'ato-l   in   tlic  iK't'iiauiii.       1  lio 
„,.•„,..  i.  turl.i.K  ami  whni  si'ttU'.l   shows  a  lai-v  aim.mit 
„,•  ..loU.lv  liiurus  at  tlu'    lM.tt..lil  nf  tlu-   .Lchiss.      Wli.'li    tlu- 
wlioK'  l.ia.Mw-wall  is  involvnl   in  tlu'  intlaimnati.Mi  the 
svnn.to,nsaivv..rvs.'Vr.v.    This  form  of  cystitis,  wlmtlmr 
.;,.i.,.i,iatii.','  in  tlu'  iK.rit.m.'al  .'ovnin-  ..f  tlir  l.la.l.l.T  an.l 
tlu'.mc  invlviiiLT  tlu"  wh..U'  Ma.l.l.T-wall,  ..r  .•..n.ni.'mniu' 
in  the  nni.MMis  nmiiihram'  an.l  iiiv..lviii,-  tlu'  nms.'iilar  an.l 
.KTit.'iH'al  n.ats,  is  lik.'ly  t..  ho  nslu'iv.l   in  hy  a  .h-tiii.'t 
ami  often  severe  el.ill,  f..ll.A\H'.l  hy  hi.U'h  f.'Ver,  .i^reat   pan. 
in    the    hvi...irastri.'    ivirion,  extreme    nitoh'ran.e  ol    th.- 
l.la.hlrr   to  the   nrin.',  an.l   aln...st    .'..nstant   iuirturiti..ii, 
th,'  |.air.  (lurimr  mieturiti..n  h.'in-  almost  hey.m.l   liMiiian 
Mi.lnran..'  an.l  a.T.Miii.anie.l  hy  a-.-ni/in-  tenesmus  ami 
evstospusnms,   often    m..."    unemlurahle    evn    than    the 
spasms   ami  teiu'smus  ..f  tin-  severest   reet.t.s.       1     une 
several    times  se.'U,  in   eases  ..f  s.'Ver.'   a.'.lte   -ron.u-rha'al 
cystitis,  retenti.m  of  urine,  ..win.ir,  prol>ahly,  partially  to 


1 


-la^seaam^KfoifS' 


r"«airTMii«;>rt*«f-ii-  .".!niiBer-:w«*  ■■MSHBti,  u:.- 


ina 


/»/>/;  iv/.s  o/'  Tin:  i,i..\hi<i:it. 


till' t  Iciiiif  niiitriirtitiii  (if  tin-  >|i|iiiirtri'  vc-ii'ii'  mill  |i:u'tiiilly 

til   til Il'llllltull'^   ilinl     >Uii||rll     rnllililiiill   nl'   |||i'    l|l'<'tliril. 

Ill   tll(-»'  cil-ii'S  till'  U-c  III'  till'  (  illlnli'l'  in'(i)llir>  ;l   in  rr-«it  y. 

I  iii'ViT  >;i\v  ii  Iniiiiiiii  liiiii'^'  >iiiri'i'  i.q'1'iilt'r  ii'^mis  lliaii 
tl'nl  a  yoiiiiir  iiiiiii  uf  >triiiii(iii>  iliiitlirois  ulm  ilinl  in  i  ul- 

lil|i-'t'  nil  till-  fi'Vclltll  llilV  n['  nil  Ihllli'  ('\>lltis  ilinl  illiiMlt   llic 

twrll'tli  thiy  (if  II  iT'iiiitnlin'ii, 

Till'  mini'  in  ii  lew  liour^  lici'iiiiii'-  mrliiil  uitli  niii<Miis 
Hi'diinciil.  iiiiiy  i  mitaiii  muih'  Mi  mi  I,  and  -miui  (l(|pii-iis  pns- 

«'((|'|in-'  Ir^. 

'I'lifir  \-*  aiiuiJHi-  variety  ot"  ariitc  ly-tiii-i  uliiili  is  i;iiiic 
('liaia<l«'ri-li''.  It  orriirs  in  luinilysis  of  tlic  lilnildcr  ur  in 
old  null  w  itii  t'lilai'i^i'd  |ir()stiitcs.  'Plir  idaddcr  is  iiol  ijior- 
oiiLrldy  riii|ilii'i|.  an!  1 1  ir  retained  urine  ( |ierlia|  is  oil  aeeoiiiit 
of  naeilli  earried  inin  the  hladdei'  liy  iinelean  eallieters)  de- 
«'oiii|ioses,  iiiid  aiiiinoiiiaeiil,  initatiiiL:',  alkaline  iiriiu-  is  tlio 
fesuli.  uliieji  oi'ieii  f.1  Is  ii|i  a  ,-ii|i|iiirative  cystitis  lli:  t  may 
ill  a  fi'W  days  iiid  fatally,  llie  paliiiit  dyiiii;  in  collaiise.  A 
lariri'  |iereelltairt'  <>f  the  mine  in  these  eases  settles  as  a 
stiinuy.  tenaeioiis  niiieo-|iiiriileiit  sediineiit. 

Sithiiriil,   (';isi:iis, — Suhaeiite  cystitis  is  always  catarrhal, 

the  liilieiilis  liicniliralie  alolie  lieinu;  in\dl\ed.       'I'lie  slllijec- 

tivi'  syiii|tioiii:-  are  ct'icii  iici;ati\i' ;  there  is  no  t'ever,  little 
or  no  jiain.  and  the  hiadder  >ho\vs  scarcely  any  intoleraiic*.' 
of  its  contents,  exci'|it  when  t'xccf^sivcly  distended,  when 
pai'i  develops  and  it  hccoiiies  ini|'os>il(le  to  retain  the  urine. 
The  characteristic  features  or  ohjectivi'  syin|)tonis  of 
these  suhaeiite  catarrhs  are  that  the  urine  is  voided  some- 
what  more  fre(|iicntly  than  normal,  is  tiirhid,  and  when 
allowed  to  settle  a  Lfrcat  (|iiaiitity  ot'  cloudy  niiiciis  is  seen 
at  the  hottoiii  of  tin.'  iflass, — not  decomposed,  ropy,  strinsxy 
mucus,  iiur  tlocciileiit  mucus,  'I'he  uriiu'  is  nearly  always 
Very  plio>phatic.  Some  of  these  cases  linally  tcriuinate  in 
u  chronic  inlhuiiiuutioii. 


nsrrns. 


103 


•If  iiiii]  iiiirtiiilly 
•  if  tilt'  iii'i'tliia, 
iiio  ii  iii'ctwsity. 
iiiT  iiL:i'ii\  tliiiii 
III)  ilii'il  ill  (III. 
is  mill  itiiiiiit  tlic 

ill  u  illi  iinii'Miis 
HI  ili|iii'its  |iiin- 

s  uliiili  'h  >;uiti> 
II'  lil:iili|i'i'  ur  ill 
iltltT  is  mil  ihur- 

li;l|iS(i||  ill  riHIIlt 

111  liillii'tirs)  i\v- 
iliiif  nriiu'  is  the 
_v>titis  tlii  t  iiiiiy 
:  ill  «'(illa|isi'.     A 

isi's   scttKs    lis    11 

I. 

Iways  ciitanlial, 
(1.  Till'  sulijcc- 
s  111)  t'cviT,  littlo 
any  intuit  raiice 
listcniKMl,  wlu'ii 
retain  the  urine, 
e  syni|it(inis  ut' 
is  voided  Sdliie- 
rliid,  and  when 
y  niiuns  is  seen 
■d,  ropy,  st rill iry 
is  lu'ai'ly  always 
dlv  terniinalt'  in 


('hl'iiillr     ^'-/«^'//v._'PI|i  re     is    no    Well-detilled    line    nl'  lie- 

niarnition  Ixl  ween  a  >nltaeiite  ey>tiii>  f  liat  liei  min's  elirnnic 
and  ail  iieiife  ei'se  that  |ia'~es  into  a  iliiunie  eunditioii. 
Wlieli  an  aellte  ease  nl'  eyslilis  lias  riMlliniled  liir  Weeks, 
|ierlia|is  tnoiitlis,  and  tlie  aeiite  syniptoiiis — that  is,  tlu' 
lever  and  ir.nst  ut'  the  |iaiii — have  in  a  nieasiin'  snhsided, 
liiit  the  tri'i|U('nt  niietiiritioii  eonliiiiies  and  there  is  a 
niiii'i>-|iuriilent  sedinn-nt   in   the   urine,  the  ear>e   may   he 

(  iill-ideled    to    have    lieeoine    ehroiiie.       As  the  ehrollie    in- 

llaiiiinatioi)  eoiitiniies,  the  Madder  euntrai't«  riuiii  the  too 
I'reijnent  evaeiiatioli,  and  the  ea^e  heeonies  one  of  eoneen- 
trie  hyiiertrophy,  with  |ierlia|is  nieeiatioii. 

When  l>lood-eor|ilisiles  are  present  in  the  sediment  Wi' 
may  Ih'  Hurr  that  there  is  nleeration.  Sonu'times  tiiere  is 
very  free  heinorrha'je.  or  the  iileer  may  perl'orate  the  wall, 
prodiieiui;  pelieystitis,  ahseess,  etc.  I'atieiits  who  me  the 
snhji'i'ts  of  ehrollie  cystitis  ari'  pi'eiry  >iire  sooner  or  later 
to  lose  their  appetite,  mid  heeoiiie  anii'inie,  weak,  and 
emaeiated.  Sleep  is  distiirhed  and  lirokeii  from  tliolieees. 
sity  for  constant  iiiictiirition ;  the  >kin  has  a  dry,  harsh 
feel;  the  patient  ii«_^es  last,  mid  looks  hiiiTirai  ..  <  ►ccasioii- 
ally  the  intlanimation  spreads  np  the  ureters,  and  pyelitid 
and  tnlinlitis  nsnlt. 

PuiMiNosis, — Most  cascH  of'rtubacntc  cystitis,  with  proper 
dii't  and  treatment,  irct  well,  a.s  do  also  a  lartrc  iiumlier  of 
the  most  acute  easi-s.  It  is  not  often  that  an  acute  lasc 
terminates  fatally,  Imt  it  frciiuently  ends  in  chronic  in- 
tlminnatiofi,  which  when  it  heeonies  of  lonj^j  standinir  is 
seldom  ciirctl. 

Tiu:.\tmi:nt. — WhiK'  the  methods  of  treatment  of  acute, 
sniiacuto,  and  chronic  cystitis  diller  entirely,  the  rules  in 
rcirard  to  diet  apply  c(pially  to  them  all,  and  the  same  may 
he  said  in  rei^ard  to  clothint;  and  rest. 

As  to  diet,  the  indication  is  to  '"iider  the  urine  as  non- 
1  :i  17 


^«»«V«'»l»<5r-v. 


■  r.:^^.~vM'.-f:  i^^r-  ~  v.»»,:.;vTr'.iTr«rj«sfC- 


VM 


Disr.ASKs  or  THE  i\i.mu>er. 


irritatinir  to  tlu-  imic.us  m.'i.il.ran.'  of  \\xv  MixMi-r  as  j.-.s- 
sil.K' ;  an.l  in  ..nl.T  to  accoiiii.li>h  tliis  it  is  of  course  iic.vs- 
sarv  to  avoi.l  lii-lily  si-asom-d  ai\<l  siMc.d  foods,  as  wi-U  as 
liiulilv  iiLroLTfiioiis  foods. 

Milk,  tier.  iMvad,  and  potatoi's  an'  suitahU'  in  every  caso, 
while  the  amount  of  m.^at  allouvl  the  patient  must  depend 
„p„„    the   sevefitV   of  the   dis.'ase.      Aleohol    an.l    t..haero 
are  to  l.e  ahs.dut.'lv  forhiddeii.     We  ean  always  allow  a 
ivasonahle  amount  i.f  meat  in  snhaeute  eystitis  unaeeom- 
pauied   l.v  murh   hvpera'sthesia,  provide<l  that  li.|Ui(ls  tn 
sufUeient"  .piantitv  an.l  ..f  ....n-irritatin-  .luality  are  also 
taken,— sueh  as  milk,  .'o.'oa,  w.^ak  ti'a,  .-..tree  ..f  m.xlerate 
e^remrth.  h"t  milk.  an.l.  as  a  rule,  pleitty  of  mineral  water. 
As  w.'  have  already  sai.l,  it  is  n..t  oidy  unneeessary  to  uso 
the  imp.u-te.l  mineral  waters,  hut  ahsolntely  imp..ssihle_t.) 
<ret  wat.'rs  of  any  country  snp.'ri.>r  t.)  th.tso  of  California. 
^  As  t..  the  .•l..thin,<r  in  eystitis,  it  is  i-ssential  to  he  warndy 
(dad.     I  have  foin.i  j.nvat  henetit  in  suhaeute  and  <'hr..nie 
cystitis  fr.im   tlu'  use  of  eham..is  shirts,  whi.-h  keep  the 
a'h.lomeu   an.l   pelvis  well   pr..te.'te.l  fr..m  the  .■..1.1.      Rest 
is  e.pially  l.enetieial  in  all  eases  of  disease  of  the  hla.l.ler. 
There  are  s.ime  torms  of  ex.r.ise  t.)  he  av.)ided,  j.artieii- 
larly   horsi'haek-ridin.-r,  li.lin.i;   in   oarriajres  over   ront?h 
stre'ets,  an.l,  for  women,  the  use  of  the  sewin.ir-niaehiiu'. 
Too  mueh  walkin.ir.  of  e.mrse,  is  injurious.     With  strict 
atteiiti.)U  to  .liet  an.l  c1othin.<;,  and  or.linary  care  as  to 
exercise,  a  lar;;.'  numh.'r  of  .'ascs  of  std.a.'Ut.-  cystitis  will 
jrct  well  without  medicine.     Oth.'rs,  atrain,  re.iuire  s.muc 
medical  assistan.'O  ;  an.l  amon.ir  the  most  ctHcient  remedies 
I  have  foun.l  are  eubehs  and  eopaiha.     I  often  pivscriho 
tw..  tirains  ..f  the  extract  or  powden;d  euhehs  with  thri'O 
or  four  trrains  of  the  inspissate.l  balsam  of  eopaiha  in  ea].- 
sule  forin  ivery  two  or  tliree  h.)urs.     S..inetimes  uva  ursi 
answers  an  exe'ellent  [.urposo,  as  does  also  huehu.     Whero 


OSTITIS. 


lO.') 


liliiddtT  as  jtos- 

»t'  ('((lirsi'  lU'Cl'rl- 

)(mIs,  as  Well  as 

K'iii  I'vcrv  caso, 
lit  imist  (U'lK'ixl 
(tl  and  toliacto 
ahvavs  allow  a 
stitis  nnacrom- 
tliat  li(|ui(ls  ill 
luality  an-  also 
fv'.'  ol'  iiKtiltTate 
'  niiiirral  wator. 
lUH'fssary  to  use 
ly  iinpossihlt'  to 
;o  of  Calit'ornia. 
al  to  !»•-'  warmly 
uto  and  chronic 
uhich  kcop  the 
tho  cold.     Rest 
of  the  hladdcr. 
I  voided,  jiarticu- 
iXi's  over   rontJjh 
*c\vin<r-niacliinc. 
us.     With  strict 
inary  can-  as  to 
cute  cystitis  will 
n,  rc(|uiri'  some 
■tHciciit  rciiu'dit's, 
[  often  ])rescrilte 
iihehs  with  three 
f  copaiha  in  ca])- 
netinu's  uva  nrsi 
)  huehu.     Where 


then-  is  some  hvpera-thcHa  nr  irritahility  1  have  lound 
e,,ual  i-arts  of  tin.ture  of  hyoscyaimis.  spirit  uf  inlr...is 
,.ther.  trlvcerin.  and  syrup  ..f  codeine,  a  drachm  every  two 
hoiirs,'to  an^w.  r  an  i.dmirahlc  purpose.  T..  tiiis  1  some- 
tiiurs  add  a.'etate  of  potassium  four  to  six  drachms  to  the 
four-oiuicc  mixture. 

Se.latives,  however,  are  not  oft.'U  m'cessary  in  >ul.acn!e 
cystitis.  !  have  made  a  syrup  of  turpentine  from  an  old 
Kivnch  formula  that  has  ^nvcn  mc  mu.di  satisfaction,  and 
iu  eases  when,  ana-mia  is  pr^^scnt  I  have  f..nn<l  say  tour 
.Ini.-hms  each  of  precipitat.-d  sulphur,  carhonate  of  iron, 
water,  and  irlvcerin,  with  chloroform  or  peppermini-watcr 
sullicicnt  t.i  make  a  four-oum-e  mixture,  answer  e-iually 
well  in  suliacute  and  chronic  <-ystitis. 

In  the  treatment  of  all  vari»'ties  it  is  well  to  keep  tho 
skill  active  hv  warm  or  steam  haths,  while  in  cases  tiiat 
seem  disinclined  to  yiidd  to  treatment  the  patients  slionUl 
sp.'ud  a  few  Wi'cks  at  one  of  our  sprinirs,  where,  if  they 
he  careful  of  their  <liet,  take  hot  mineral  haths,  and  drink 
from  four  to  six  pints  of  mineral  water  daily,  tlu'y  will 
ottt'ii  net  well  in  a  short  time. 

Aoutc  0/.n7/7;.v.— The  treatment  of  acute  cystitis  depends 
entirely  on  the  amount  of  hladder-involvement.     When 
tlie  inilamination  is  coiittne<l  to  the  mucous  memhrano 
there  is  little  fever  to  he  comhated,  and  the  pain  is  not 
usually  severe.     With  attention  to  the  rules  already  laid 
down  as  to  diet  and  rest,  hot  applications  over  th.^  rcirion 
„f  the  hhnlder,  plenty  of  warm  demulcent  drinks,  warm 
rice-  or  harley-water,  flaxseed  tea,  or  dec-oction  of  tritieuin 
repens,  and  the  twentieth  of  a  irrain  each  of  sulphate  of 
morphine  ami  tartrate  of  antimony  every  hour  or  two,  (.r 
iive  irrains  <.f  Dover's  powder  every  two  hour>,  or  tincture 
of  h'yoscvamus,  spirit  (.f  nitrous  ether,  and  syrup  of  mor- 
phia',  of  each  a  drachm,  in  water  every  hour  or  two,  will 


AiirtSsSMBewKtiaw'KstB*  ^■ffl''--  «■"' 


iO« 


nisi:Asr.s  or  rni:  i:f..\ni>j:/r 


oft. Ml  be  ill!  tlif  iiK'.liciitioii  tliiit  i<  iirrrssarv.  S(.nu'tinK's 
iriTiit  relict'  is  (.l.tiiiii.'il  tVom  a  mixtiin'  of  ten  to  litU'cn 
irraiiis  (.f  l.roini(U'  oi  (.otussimii  and  five  .un-aiiis  of  rliloral 
hydrate  I'Vt  rv  two  or  tlirct-  honiv. 

'  W'liri-c  th.'  muscular  structure  ami  perliaiis  the  perito- 
neal  iiiciiil.rauc  as  well  are  involved,  as  has  already  been 
stated,  the  pain  is   very  s.-vere,  fever  often  hi.irh,  eysto- 
si)asnni>  pn'Si'Ut,  and  the  tenesmus  of  the  hladder  extreme. 
Ilypodermie  injeetioiis  of  morphine  are  othn  lu'cessarym 
these  cases.      Lar<re  rectal  eiiemata  of  hot  water  sometimes 
assist  in  i^ivinir  relief,  and  it  is  usually  necessary  to  resort 
to  supposititries.     1  often  .ijive  in  that  form  morphine  .mo- 
lialf  irrain  with  extract  of  hyoscyanms  live  irrains  every 
three  or  four  JK.urs,  at  the  same  time  applyintr  heat  to  the 
sacrum  and  over  the  hladder.     ( »c.'asionally  there  is  re- 
tention of  the  urine,  when  it  will  he  neeuasary  to  use  the 
oatheti-r.      In  all  these  severe  eases  opivnn  is  the  medicine 
that  irives  relief  most  spiedily.     I  have  found,  however, 
that  chloral  hydrate  in  ten-  or  titleen-,irrain  (h)ses,  with 
one-eiirhth  of  a  .irrain  of  morphine,  will  ofton  act  admir- 
ahlv.      In  some  of  the  very  worst  cases  a  few  days  of 
this   treatment    will    hrinjr    relief,  when    tho    h()t    appli- 
cations   may  he    suspended    and   the    amount  of  opiates 
lessened.      When  any  of  these  cases  hecome  chronic  the 
treatnunt   must  he  chan-red.     The  fevi-r  will  have  .lisap- 
peared  and  the  pain  lar-rely  subsided.     The  bladder,  how- 
ever, still  remains  irritable,  may  be  (piite  contracted,  and 
pus  and  mucus  still  be  observed  in  the  urine. 

The  balsams  here  an-  otU-n  of  iH'notit,— balsam  of  co- 
paiba, balsam  of  IVrn,  and  turpentine.  I  have  found 
their  eflica.y  assisted  by  condunation  with  ereasotc. 

Creasote  alone  often  acts  well  in  chronic  cystitis,  ospe- 
eiallv  where  there  is  a  tendeney  to  fermentation  and  de- 
composition of  the  urine. 


^.--j*-i*aWR  -  ■^»:— W*»»»W«3g*ft»CVtt 


rysTiTis. 


11>7 


AnotluT  ivnu'.lv  fomxl  l.riull.ial  in  .•l.n.iii.-  .•vstitis  in 

l»i'ii/()i('  iui<l. 

Sulol  I  liiivf  lat.lv  trir.l  with  iK'Hrtit.  1  liavf  als<.  iia.l 
assistati.v  from  salirvlati^  of  so.limn,  an.l  l.avi-  fomi.l  sa.- 
rlianii,asivromi.u-n<lr.l  l.v  Dr.  LittK-.  of  DuLlii..  to  yvosy 
iK-ni'H.'ial.  In  a  lar-r  miiiilHT  ..f  .'a.,  of  cl.ronir  cvstitis 
inoiv  iHMM'fit  has  Ihvm  .Iriivnl  from  loral  applhatioiis  ami 
washiiiir  .)ut  tin-  hla.l.h'r  than  from  ihr  int.-nial  a.lm.ms- 
tnitioii'of  mfdirim.s.  i^>rati'  of  so.lium  makrs  a  .ltoo.I 
l.ri'paratioii  for  washiii.tr  out  tlu-  l.la.hh'r,  as  .lors  also  a 
wiak  sohition  of  horacic  aci«l. 

Woak  solutions  of  chloral  hy.lrat.-  answer  a  .r<">'l  l"»r- 
j.osc,  an.l  few  thing's  aiv  h.tter  than  a  s..lution  of  .•ommoii 
salt,  a  (Ira.'hm  to  tho  quart  .(f  water. 

Nitrate  of  silv.'r  an.l  nilri-'  aei.l  have  also  been  n'.-c.m- 
m.Mi.le.l,  hut  it  will  he  h.-st  tirst  to  try  almost  any  of  the 
other  r.'ine.lies. 

lu  obstinate  eas.'s  in  w.)men  it  is  sometimes  noeossary 
to  estahlish  a  vesi.'o-va.ijinal  Hstula,  hy  whieh  means  the 
hla.hler  is  kept  constantly  draiiie.l  ami  the  intlanunati.m 

remove. 1. 

When  ther*'  is  e..ntraeti.»n  or  .'om-entric  hypertr.tphy, 
,lilatati..nof  the  hla.hler  is  ne.vssary,  the  .lir.'.ti.ms  ton 
a.vomplishin.LT  whieh  are  ,i;iven  under  the  treatm.'ut  of 
that  .'on.lition. 

It  is  har.llv  necessary  to  say  that  while  pursuing  this 
course  of  treatment,  either  by  the  a<lministrati.)n  .)f  ine.li- 
.iues  or  hv  local  applications,  the  dietary  rules  canix.t  he 
too  strictly  enforced,  uii<l  the  i.atient  must  abstain  from 
ali'oh.dic  beveraircs  of  all  kinds  an.l  fn.m  tobac.M>.  In 
i^pite  of  all  onr  etibrts  we  are  sometimes  .lisappointed  with 
the  results,  there  heiui?  few  diseases  less  amenable  t.»  treat- 
ment than  chr.tnic  intlammation  of  the  bladder.  As  has 
been  sai.l  in  the  proirnosis,  viM-y  few  patients  ever  i;et  eu- 

17* 


l-.M2»^"S»«Sl'*P5rj*'.»*  "W  I"--  ,«aSt.'~nS!W 


raja^,r-ft;r:iif:?'^.--«^»»^'^'aBni»w«a^ 


108 


nisK.isKs  (>/■•  Tin:  iii..\niu:i{. 


tinly  w.U.  It  is  woiid.  rful,  Iiow.mt.  1im\v  h.iih' of  tlic 
v.TV  w.rst  .•as.'s  of  .hnmir  .-y^titis.  wl.i.l,  Law  ivsistr.l 
all  our  .■H;.rts  t(.. ■lire,  will  1...  iiui.n.vr.l  l.y  a  trw  w.vUs' 
,„•  n.imths-  suinurn  at  thr  llinlMU.  Uaftlrtt,  Z*'i.irl'T,  Paniiso, 
lli.irl.hiii.l,  Nai'U  So.lu,  ..!•  any  otluT  ..f  our  Califuniia 
liiiiifral  spriiiirs. 


(11  A  I'TKli    X. 


I'KKlfYSTITIS. 


l.v,.„„,,„iV._ri(Ti-s  soiiu'tiiiiis  iKTt'onitc  tlu-  l)1a(l(U'r-wall 
Hiid  icivc  rise  to  luTicyslitis,  and  ocvasioiially  an  aciito 
cystitis  without  ulci'i-ation  I'Xtfiids  thn.u.irli  tlu-  l.lad.U-r- 
wall  and  involves  tin-  suri-onndin-'  cclhdar  tissue. 

in  chronic  cvstitis  there  is  often  sonu-  i.ericystitis. 
Al.out  f..ur  vear's  asro  I  had  a  :ale  patient  in  whotn  .iTon- 
„n-h.ea  ,xti-nded  to  the  hla.hi.  tlu'  cystitis  hein,<r  very 
acute  and  cniniinatin.ir  in  a  severe  attack  of  pericystitis. 
It  may  also  occur  from  intlammation  of  <.ther  or,irans, 
such  as  the  rectum  or  the  uterus,  or  of  the  peritoneum. 
A  year  a-xo,  I  had  a  female  patient  wilh  i-elvic  j^eritonitis 
accompanied  hv  a  pericystitis. 

Pericystitis  may  follow  any  of  the  acute  infections  dis- 
eases. 1  have  had  in  my  practice  a  case  of  pericystitis 
foUowin-  typhoid  fever.  Septiciemia  is  an  etiolop^al 
factor  that  must  he  home  in  mind. 

Symi-T()M.s.  — The  symptoms  of  pericystitis  occurrinsr 
duiiiiu'  a  t'ystitis  are  .irreat  increase  of  pain  over  the 
hladder.  usually  retention  of  urine,  recurrent  chills,  in- 
crease of  fever,"  and  iri'iu'rally  tlu'  formation  of  ahscesses, 
wliich  can  be  felt  throu.i;h  the  va.irina  or  rectum  or  ahove 
the  puhes.     The  abscesses  may  open  into  the  bladder,  the 


V  ot"   tilt' 

resisted 

■    \V('l'i\S 

l';n'iiis(), 
iilit'i)niiit 


iiYVKitriidi'in   "/•'  '/'/"•■'  tii..\nDi:ii  199 

r.-ti.i,.,   or   tl.e   luritniu:.'    ravitv,   or  tl.rou,L'»>  ll..'   lu-ri- 


iii'iim. 


Ill  flu-  i.cri.-vstitis  nccomi-iiKyinu'  clironie  rystitis  tlio 
irroiin.liii,-;  ci-ilular  tissue  is  otU  ii  inaurated  mid  adlu  nut 
to  tiie  ;id)aeent  parts. 

Tkimmknt.— Tiu-  medi.-ation  must  1h>  directed  to  tlu- 
ullcviation  ..f  the  iiiereased  severity  of  tlu-  symi-toiiis. 
Opiates  iire  .U'inaiide.l,  tin-  eatlieter  is  likely  to  Ik-  luros- 
wirv,  and  abscesses  iiiiist  Ik-  t-vaeiiated. 


1 


Ider-wall 
111  acute 
hlatlder- 

i-ic-ystitis. 
olii  iToii- 
■iiit;  very 
rieystitis. 
•  origans, 
itoiu'Uiii. 
eritouitis 

tiourt  dis- 
c-ricystitis 
tioloLjical 

neeurrillir 
ovt-r  the 
chills,  in- 
ahseesses, 
1  or  ahove 
iddor,  the 


(MIArTKU    XT. 

llYPKKTllorllY    OK   TUK    IM-ADDKU. 

TllK  term  hvpcrtrophv  of  tlu-  bladder  is  used  to  desi,!;- 
nate  thiekei.in-  of  the  blad.ler-wall.  The  hypertrophies 
of  the  bladder  are  divided  into  two  varu-tu-s,— nann-  y, 
..oncentric  and  excentric.  Tn  concentrh-  hypertn.phy 
there  is  a  thickened  wall,  with  a  diminution  ot  the  cavity; 
i„  excentric  hvpertrophy  there  is  a  thickened  wall,  with 
enlar.'ement  of  the  bhuhler-cavity.  These  two  varietur 
ditf.r  in  their  etiolo.ijy,  uivatomical  ai)pearauce,  symptoms, 

proo-nosis,  and  treatment. 

F-nouxiY.— r'<-//r<v(//vV-i/v/>.77r<v)%.— Coiu'entnc  liyper- 

troi.hy  i^  i-aused  by  or  accompanied  with  inflammation 
or  livpt-rsvsthesia  of  tho  bladder. 

DuriniT  a  cvstitis  or  a  hypenesthetic  condition  ot  flu- 
bladder '^he  oWm  i^  very  intolerant  of  its  contents,  and 
micturition  is  excessively  Vre.pient.  The  bladder  is,  ot 
course,  never  .listende.l  with  urine,  and  hence  becomes 
contracted.  This  condition  occurs  irrespective  ot  tlu- 
cause  of  either  the  cystitis  or  the  hypera'sthesia,  there 


ffl»s»«W*iKSiW!rs...s^«C,:s'a»»««ts«,e»r»--w 


-i!«ot.s;.»*.,r<w-^a*»s*-»as:i'>s?--^»~*^' 


Bsjis<«aB!»»fr"-sra!;»='""^*"-»*^^^ 


I 


200 


DisK.isr.s  OF  Tin:  iii.MU)i:n. 


l.fiii-r  t»'vv  «!i'"'^  uf.lin.nir  cvstilis  that  .1..  not  i'li.l  in  .■..n- 
fi'iilri.'  hviuTtrnpliv.  It  is  .niit.-  .■..iim...n  t..  tiii.l  .uiH.n- 
trio  liyiK'Vtfoj.liv  wiicn^  tluMv  is  a  vrsiral  raKiilus.  wli.ll.t  r 
til."  stum-  has  caiisrd  much  iiitlaimiialioii  or>imi.lv  l.vp.T- 

pcrtn.i.hv  is  oiitiivly  .liHoiviit.  It  .oiu.s  iVum  an  ..I.- 
HtiMi.tinnt..  thr  cvacnaliou  •:'tli>'  .'..iitciits  of  the  hla(hKT, 
will  If  tluTc  is  no  hyju'iii'stln'sia. 

In  these  cases  tlie  lirilie  accuiimhiles  and  disteinU  the 
Ma.i.hT-cavitv,  and  it  re(,niirs  extra  niuscnhir  i'.xeftion  to 
emptv  the  hh"i.lder  of  its  contents.  The  musenhir  coat  of 
the  hladder-wall  hi'conies  hyiK-rtn.phied  uikUt  these  cir- 
ennistanees  upon  the  same  princii-U'  as  tlie  heart  liyper- 
trophies  to  overcomi' I'M  raordinary  resistance,  as  in  arterio- 

'sch'rosis  for  instance;  that   is,  tlie  hypertropliy  in   hoth 
instances  is  compensatory.     Tlu'  ohstnietion  is  irc-uerally 
an  cidar-re.l  prostate.     It  n.ay,  however,  he  stri.tnr*' ;  hut, 
as  a  rnU",  the  ohstnietion  of  stricture  is  likely  to  he  a.-eoin- 
panied   hv  more  (U-   K'ss    hyju'ra'sthesia  of  the    hhuhh'r, 
which  in  a  measure  prevents  this  distention,  and  intact  this 
f.irm  ol  i.hstnietion  mi,u;ht  also  produce  concentric  hyper- 
trophv.      I  helieve  that  a  phimosis  ini,-;ht  he   responsihle 
for  hvpertrophv.  either  i'..ncentric  or  excentric.  thou,i;h  I 
have  "never  nu  t"with  a  .ase  ..f  this  kind.     Diahetic  patients 
are  fre(iuently  the  suhje<-ts  of  hyportrophii'd  hladder  of 
either  variety.     Those   diahi-tic   iiatieiits  who   have   con- 
centric hvpertn.phy  are  ju-rsi-ns  in  whose  clinical  history 
there   is 'not    the   symptom    of  ,irreat    thirst.      They  take 
very  little   tluid,  and   complain   irenerally  of   irreat   mus- 
cular   exhaustion.       The   urine,  not    l.ein^i;    increased    in 
.(uantitv,  is  of  hiirh  speciiic  .ijravity,  and  contains  a  larifo 
amount  of  suirar,  which  is  very  irritatin.ir  to  the  hUuUler. 
It   is   the  constant   micturition  that   prevents  distention 


^t 


,,,..ft*.^f»Vli.—-e'ft'.r' 


■-_-^  .••■.^)(;i,««AA-*i*.lt*-^-.  '^■- 


..  ^it.~tvrmtciu:i*,^t:., , 


iiYVKimtoriiy  or  riii:  in.  \i>i>i:i{. 


m 


.,„,   ,„H..  .■.M.s.Mumt    ..o,H.....nr  l.viKTtrupl.v       In  .lia- 

■     J    vuM.t..n.,  an.l  wl...  n..l.UK.  ...on -  M-;  ^ 

r  vatH^....l  H.m.t.  a  uMvat  a...o,.,.t  of  ....... ..!..•  I'l-M-^ 

:,:;;' othy,u..-a.t,.ti..  I -->•-;•'-'-"";::  ^^^ 

,.,  ,,,,.1   so  ,.,v;.t  a  H''a..titv  t'.v.i'U..tly  .a..s.  a  t.,..    *x 

,,:',,iu.On....  .l..-..ni.-.-y.tUistl..s..,-ta.vot   ,1..  nn,.;ous 

n.l    ,lu.   i.loo.l.vc.ss.ls    a.v    .lilatM    ai..     U.Uu^. 
T  ,  ,  is  .U.SMn:....a,lo,,  of  tW  .puMiu...,  a...l  VH'V  .m..^ 

,  ,,„,,tion.     Tlu.  l.laa.K..-waU  is  so.„.ti.....s   v...oi;...o..sb 

k  1"      I  l.av.  s..,.  it  al.oMt  o.u.  i..-l.  u.  .h..k..-s. 

S^i;;t;;is.on....t.-i.  variety  the  tl.i.U...i,... snot. ^ 

^.„n,vlv  to   ...•,.s..„la.-  l.y,K..-tro,,hy,  as  ts   .,s,.a  1>    .tat 
T,    .v'h  a,.   i....vase  i..  ,uM-..svth  of  tl.e  tilM-o..s     .ssue  ....- 
.        li  ..;  tl.e    .....s...lar   lascintli,  a...!   i..   u.na,m..atory 
:     tW,v  is  also  a  ,.vat  i.K.rouse  i..  the  ,n.wtl.  ..      u- 
,;,,.,,^,,  ,,Hih.ous  tiss,.e  ..f  the  ....u-o,.s  ,.,e...l.ra..e  a>   Y 

\.,-  the  s..h,n..eo..s  eoat.      ^he  st.l>se,,,.eut   eon  ..^^^^^^ 
,Ohis  t.ewly-to.-...e.l  tissu..  a.hls  very  .....eh  to      e    h     k 

,,i„,  of  tl.e  wall,  so  tl.at  eo,..e,.t,.e  l.y,K.-t...  .h    ,  -    t^ 
,,U:iJsha.-aiyat...ehy,K..-t.-o,hy;.....eho    the    h    k^ 

,ni,..'  is  ..o  ao..ht  .hie  t..  the  ..o,.t.-aet.o..  ..t  th.  ^^.'l^ 
r;h^..ke..i..,  ..f  the  st.„..a..l.-.all   -->lts     -....-. tn 
ti.,„  whe.v  there  exists,  for  n.sta...-e,  a  str.(t...e  .  t   .1. 
!;:s.;,ha,n...     This   thieket.i.,.  ..f  the  st..n.ueh  .s  elea.l> 

not  an  iiyi'iTtrophy.  w  ....v  thirk- 

1,1  exeenfi.-  hypertrophy  there  .s  ve.;y  Uttle  ,f  ans  th,  k 
enin.  ..f  the  n.ueous  n.e...hra..c,  nor  is  Uh  suriaee  .rreK..la. 

•^;t:l;ti.larKeu.nlthewallisthu.k,h..titist^ 
nuLlar  .-oat  aUme  that  is  thieke..ea;   m  other  ...hK 


*i6e;OT^:?**'2StVC£J  »/irWaSW'"»- 


,rKMV-Jj-AA;,»<-*-'-.4Ai^*»^*"*'*^'* 


■■Mi,  .^'.<i  .Miin-MteK,'4m^<»^  - 


mm 


202 


insi:.\si:s  or  riii:  nr..\ni>j:/i. 


i.    I: 


I   r 


lliiTf  is  a  tnic  li_v|«i  rtro|iliv,  !>r<>iij.''lil  iilioiit,  as  we  have 
alifailv  sciii,  liv  llir  tlToits  ut'  ilic  imiscular  wall  of  tin- 
liladilt  r  to  I'Xpfl  tlif  (■(iiiltiits  ol'  llif  (ti'uaii. 

SvM|.|nMs. — III  ((tiici'iitric  li_v|K'rtr(i|iliv  tin-  usual  syTiip- 
tuiiis  art'  llmst'  ol"  cliroiiif  ivstitis.  rpoii  idivsical  ixaiiii- 
tiatioii.  Ity  the  liiiiiaiiiial  iikIImkI,  wc  liiid  the  tliirUnicil 
I'diitraftnl  i.lail«l(i\  t'nliii.ir  lil<t'  h  huvA  l»all,  ln'liiii'l  tlu' 
itiilns.  WIh'Ii  tin-  ((mfriitiic  li_\  itcrtropliy  is  diu'  to  liyiicr- 
ii'stliisia,  till'  syiiiittoiiis  t<\'  clironif  cystitis  aiv  lacUinir. 

Ill  (Xiciitric  liyiurtrivpliy,  i'Xi'i'|it  in  diain'tt's,  \vi'  liavo 
tilt'  flinital  history  of  tin-  oitstniftioii  wliidi  faiisi'd  tin.' 
dilatation,  ami  liinl  oil  I'Xaiiiiiiatioii  a  lai'iri'  liard  tiiiiit>r  in 
tlu'  liy|io<i:asti-if  n'<.'ioii.  Soiiu'tiiius  ilu'  liyin'rtrt>|iiru'tl 
lilaildtT  fNti'iitIs  u|»  to  till'  imiliiruMis.  Tlit'i'i"  u'.'iH'i'idly  is, 
al">,  liyiurtro|iliy  of  tlit-  iimscK's  of  tlii'  aluldiniiial  wall, 
from  till'  ftlui-ts  of  tlii'st'  iiiiisflt's  tt>  assist  tlit-  MadtltT  in 
I'xiit'lliiiu:  its  fonti'iits.  Till'  strainiiii;  to  fxpi'l  tln'  iiriiu' 
oftfii  t-aiist's  jirolapsi'  of  tlu-  rcftuiii,  ami  soimtinus  fiii- 
jiliysfina  ami  Inniifliitis. 

I'lcdiiMisis. — 'riif  iin>,irMt>sis  dcpt'iids  upt)ii  tin.'  etiology 
and  pathology  in  the  individual  ease. 

in  dialietes,  when  the  patient  is  eiired  of  the  primary 
disease  the  hypertrophy  tlisappears.  The  exeeiitrie  hyper- 
trophy tlue  to  eiilargeil  prostata'  will  often  tlisappear  under 
the  prt>per  use  of  the  eatheter.  The  progntisis  in  the  eon- 
eeiitrie  liyi>ertrophy  whieh  aeeoinpanies  ehroiiie  eystitis  is 
bati,  as  it  is  also  wlien  the  kidney  is  iiivtdvetl. 

TitKATAiKNT. — III  exfi'iitrie  hypertrophy  due  to  prostatic 
t'lilargeiiieiit  the  constant  use  of  ti  st)ft  jierfeetly  clean 
eatheter  entirely  relieves  the  patient  of  everything  but  the 
eiilartretl  gland.  A  few  years  ago  I  was  called  to  see  a 
geiitleiiiaii  whtise  condition  was  wretched  indeed.  lie  was 
unable  to  leave  his  bed,  the  pn)state  was  very  large,  the 
hypertrophied  bladder  (cxeentrie)  formed  a  large  hard 


'^"'W.iUfr-'ie  ■■ 


rv:3gfw  ^J..^lJJ^^^H■^.«l«tiP^■''l^a^gIrig1^iWWg«w?':^-^^v.**^?'^?g*«^^**'^■^^ 


.vKii-  /./.•OH77/.S  /.v  77//:  ni.Anni:n. 


20fi 


,,,,,,,,,  ,,,,t,,n,n.l..M  to  ,h.mnbiU.MH,:m.ltl..alMl..m 
U.S  w..,v  nuul.  tl.i..U.u..l.      Anv..fl..r.to,.as.wat. 
Ll,rola,.-<.rtlu.m-tun,,an.l,ina.l.lmon    1.;..^^ 

:taI.tns..o.Ml..H.n<.a.!u..n-atn.,ularn.U.na.s.m^^^^ 

tlti..  .Mlar,.-nu-Mt  an.l  tlu-  ..ui.l.vso.na,  a.M  1>.  .vsmu.-l 
lii-*  \\<\\a\  occiiiiatioii.  .  ,  ,    ,  ,  4. 

l„.  ,lila„..l  «i,l,  «„.,.,■,  a.  1,...  a,  ,;a„  !„■  l.........  -  ,1,  T 

:;:.!ivt;atnu.ntn,rthe.ontnu.tlonis.lila.anon  .^ 

l,u,suc.;i  this  .ourso  t^>r  ci^htc..,.  y.ars,  -'»'/-';;  ^^ 
I,,,,  of  surcss  than  aay  otlu-r  trcann-nt  utU.  nl.     ^^  l.n 

.^Ll  ai  well  us  aistond.l,  1  use.  a  son  donUU.  rubber 

cutUeti-'r. 


C  II  A  r  T  K  U    X  1 1. 

N.W    ..ROWTIIS    ANU    KOREiON    BODIES    IN   THE    ni.AU..KK. 

While  the  treatment  of  new  jrrovvth.  and  forei^-n  bodie. 

is  essentially  sur^ieal,  it  is,  -^^T'^'''''''  "7:::Zlt 
,,,tter  of  <liaj.nosis  or  ditn.ent.al  f •''^-^-j^      ^^^'^'^ 
Bieiat.  should  understand  their  etioh.-y  and  symptoms. 
Z:.Z  are   divhled  into  two  great  elasses,-ben,gn 

"  N:^h!^'al^'so  common  in  the  bladder  as  elsewhere  in 


a,a«»«ri!««B»«e«=^ 


s«as»irw«iwpi^"«i>**'>""™'':' 


'  I 


204  lusEAsF.s  or  Tin:  i',i..\niu:n. 

iMiuniiH  jiifiiiliniiH-',  wliicli  is  ilitiilitlfs-i  owiiiir  to  tlif  I'ii'f 
tliiit  ill  liu'  lihnlilrr,  •x.cpt,  it  iiiav  ln',  in  tiif  vicinity  •'!' 
till'  iiifk,  tlic  niiifoii;  un'Mil»fun»'  is  jkhh-  in  sccn'tinif 
;rliiinls,  Hunn-  iiutlmfs  ii^sfrtintr  lli<ii  iniil>ililv  to  linil  iiii.v. 
Mijt,  liowi'ViT  h'ss  tVfinn'iitly  tlusf  ^'louili,-  o.riii-  in  this 
incniliraiii',  we  tiiMl  tlif  siiini'  varii'tv. 

'I'lic  bciiit^M  tri'ou  llis  ioiii|irisc  nivxoniii,  liliroinii,  mvoiiia, 
invo-tiltfoiiia,  ami  tiiln  rclc 

Till'  \aiiriirs  nf  tlif  iiialiirnaiit  arc,  as  iii  oiluT  orLraiif*, 
♦•|iitlnlioiiia,  iii.'c|.lialoii|.  sriirlnis,  etc 

\Vf  know  as  little  of  tin'  rtiolo!.'y  ot'  these  new  -.qowtlis 
1   the  hhuliler  as  we   <lo  of  the    iiew   >;rowths   in   other 

nieolis  Iiielllhraiies. 


Ill    the    l)la«l<ler   as    we    «lo    ol     tne    new    ^n-owins    III    oilier 
linieolis  ineHlhraiies. 

The  syniptoins  ict'erahle  to  the  I'la.Mer  iliU'er  hut  little 
whether  the  uTowth  is  heiiiirii  or  nialiirnant,  the  pain  and 
initatio:i  heiiiir  "liie  to  the  loeatioii  and  si/.i'  ol'  tin-  ixi'owtli 
rather  than  to  its  ehaiaeter.  Constitutional  syiniitoins, 
howiver,  are  imieh  more  marked  in  th«'  mariirnant  than 
in  tlK  heiiiiTii  variety,  ("aneer  of  the  hladtler  produces 
the  usual  characteristic  ca<'hi\ia.  while  the   profound  aii- 


^•C. 


^.•■■wt^.rr-Wt'-l-.t-i.***'  fc'.^ry^^';**'^-'' 


.-   .j-*«tU^:-S-«J»^<rf>'C*JiC^*«®**Wt''**^*'''^^*M*'i'*J^ 


,,i^.th..>umM.ill..■^in.l.•MK.l..o^iM.I.•lH.u>^•;^vl.il^ 
^•„,....,nl ,....     'nu..u...Hv..rtl..v.. .1.  .an  ...  n.auv 

Tl,..,vis.H.  .M.l.a^to.l..    s..vm.V..t    .1...  ..NMu,.V...l 
.„„.,.„,.,,,„„•„,,  ur  .!..■  .M.r.ir.KU..   tn. -.      I  "•u- 

As  "  l.av.  :.l...a.ly  ..i.l,  the  t.vatn....t  of  th..v  ,'n.wth« 
IK  fSKoi.tially  Hi..\i,'i«'al. 

FOUKKiN    noDIKH   IN   TIIK    MLADDKU. 
AV.  ...av  .ns..ov..-  i..  tlH.  l.la.1.1..,-   ^.vi^..   '""1--^ ''';';' 


;;;.;.„.;a.l...i.-wavi...otW.avi,ytln-o.,,h,tsw^ 

■.,utl..u,vt..-s,o..l.yway..rtlu....vth.-..  .. 

,,H.,vi.atr.vatva.Vty:  .l.nno.l  t.....o.s  <..•  t-rtal  1   m. . 

,      xt.-:ut..-i...  ,.v,..a....y,  ;..n-sto,...s  o.-  ......tH.t.  ot 

'  ..n.sti..os,  all  of  ul.i.l.   .nay  a.ll...v  »<>  a.ul   uU...,-ato 


tlin.iiirli  the  walls.  -if  i„„,..c 

(i.u.shot  wo,....ls  ,..ay  nuM-y  l.ulh.t.,^'W''nl.v'  ot  h...H>, 

or  l.it^  of  c-l..thi..>r  into  thf  l.la.hUT. 

(;lvvl-..o„or.tio..s  tVo...  th.  ki.hH.y.,  o..t..Mn^  the 
,.,.,,.,.  l.v  wav  ..f  the  n,H.t..-s,  ...ay  Ikh-o,.,.  the  ..u.h  . 
olCe  BUme.,  o,-  hy.lati.ls  ,..ay  ...tor  it  1.-0...  the  k..l- 

.ItV. 


.■atl-iH' 
n.aiiv  other  eurious 


s  articles  have  been  fonml. 
18 


«i^««iv4a9VAu>i'' 


,-,-.^.-i:«*^.;^raw»' 


.H--na<?»i-*«JWt^'^ ' 


,«fl#r,-,-.:^.«ft,'-»V"-»^ 


•'(Ml 


insi:.isi:s  nf  Tin:  hi.\i>i>t:ii 


>  r, 


Tin-  lilt  mis  of  iliiiirii.mir*  me  tlif  l»iimiimiil  ('Xiiiuiiiutiori, 
tin'  Hiiiiinl.  iiml  tlir  tiiilH.((i|M'. 

TIh'  irialiiuni  i'*,  «•!'  .oiirsf,  Hiir^'i<al. 

TI'IIKIH  I'l.OSIS   OK   TIIK    llF.AUKKIt 
TlllllTfUlnMS  of   tlu'    ItlailllfP    i""    prol.ilMv   VflT   r.tl<l.>|||  a 

i.tiiiiarv  disease.  In  tlu'  male  it  is  ii>iialiv  assnciatiil  with 
tiil.(f.iil'>:.is  of  tlif  trstiilc.  tin-  kiiliuv,  ami  orcaslonallv 
III.'  iuMirs;  wliilf  ill  tlir  frinal.' it  is  c.iirrally  acroiiipaiii.d 
l»v  tiilKiciilosis  of  llif  kitliH'V  or  tlif  liiiiifs. 

TInTf  is  mails  always  laciiiatiiria  at  sotiic  i.tijoil  in 
till'  roiirsf  of  llu'  tlisrasf,  lilliii'  from  tlif  Ma.l.l.r  or  ihc 
kitliii'V  or  from  liotli.  wliiU-  tlio  ulceration  ami  tliickiiiiiij; 
art'  likfly  to  involve  tin-  wlioU-  K'iij;tli  of  tin'  iinti  rs. 

W'c  have  alrcatly  irivcii  a  <litail.(l  acroiinl  of  tla- 
patlioloirv  ami  syniptonis  in  tiilnrriilosis  of  the  kidiu'V. 
An  »'\ainination  witli  tin'  cystoscoiK"  will  sliosv  cxtciisivo 
111. •.•ration,  ami  tli.'  nrinc  will  W  found  loaded  with  piini- 

l.nl  matter  and  oeeasioiially  to  eonlain  Id 1.     Himaniial 

exaiiiinatioii  l«y  flie  riTtum  or  vaL'ina  shows  a  thifk.ned, 
irreunlar.  ami  lender  comlition  of  the  l>ladder. 

r\Tiini.oiJV. — 'Piiliereiilosis  of  the  Madder  eonimenees 
in  the  siihiiimoiis  tissue,  iriviirir  the  mucous  luciiihrano 
an  irr»',irular  aiij.earam'e.  The  deposit  is  at  first  irelatiiioiis, 
hut  soon  hecoiiies  ojiaiiue  and  cheesy.  As  the  clu'i-sy 
deposit  softens  it  involve?  'In-  uiucous  nieinhraiie.  jiro- 
diminix  characferistie  tnher.  iilar  nlei'iation.  the  urine  e.ni- 
tainini'  juis,  hloo  1,  and  disinteirral»'d  tissue. 

'rreatnieiit  is  jialliative.  washimr  out  of  the  hladder,  etc., 
Iti'inn  i;.iverned  I'V  the  coiiiplicalious. 


»  ^'n^n.-^^.^tfWitvO*^^ 


initiation, 


^ 


1 


KMiir.sis  sntrrus.t. 


•207 


•'t'liliiiii  ii 
atcil  uitli 
•asioiiiillv 
Diiipanit'd 

|ii'iiui|  in 
Ici-  or  till' 
liicki'iiin^ 

I'tfl'S. 

It  i>r  tiic 

I'  kitliii'V. 
t'Xtciisivo 

k'itll    |>U!'II- 

irniiiiiiiial 
liiiUciicil, 

nimiriiccs 
iiciiiliraiu' 
fi'lntiiKiiis, 
lie    fliri'sy 

rant',  pro- 
nriiif  roii- 

lldtT,  L'tC, 


(•  11  A  r'i'i:i{  Mil. 

|:MIU>1S    Nh.I     1  NA    (NnrnUNAI.    INCONTINKNtK). 
TllK  rtinl.M'V   Ull.l    pullinlntrV   nf  tills  .•.•lulilioll  alV  llS   Vft 

v.TV  uUmuiv.  n.if  is  it  |.ns.il.lr  to  ..xplaih  vvl.v  it  in  ain...Ht 

c.ntitvlv  .M.ntinr.l  t..  rl.il.livn.     Wli.n  It  uis  in  adnltrt 

i(  i.  piMTallv  till"  ivsiilt  of  n.r.li.iins  or  i.aivoti.-s;  in 
t;,.t.  it  i^'  nut  a  Vi'fv  unusual  tl.ini;  lor  nun  wli<.  >,'..  tu  l.r.l 
.Inu.k  to  l.avi-  tlii-  .•..nt.tits  of  llnir  l.la.l.lcfs  rH.apo  tn- 
voluntarilv.  TIn-ro  aiv  inanv  tlioofii-H  advan.v.l  as  to  tlio 
.,..,nal  <aus,.  of  tlli^'  n.ndilioii.  iait  noin-  of  tlimi  aiv  satis- 
,„..,orv  If  tin-  .•ontcnts  of  tla.  i.l-l.U-r  .'s.aiM.  Lcausi, 
„f  pui'alvsis  ..f  til*'  spl.in.t.rs.  wl.y  is  tlniv  no  paralvHis 
.Imiu"  "tlu-  ilav?  (»n  tl.r  ..tluT  l.an.l,  if  it  is  i.ur.y  a 
sonsoiy  neurosis,  why  .lo.s  tlir  .listiirban.v  or.iir  only  at 

'"~It'liasl..'.'nsuu'LCi.st.'.l  that  with   .-hihlrni   thus  afU'cti'd 
sh'.].  is  unu.uaUv  |.rofoun.l :  hut    1  do  not  >..•  thai   this 
MlVords   a    satisfactorv  i'Xi.lanati.ni    of  th.'    inrotitiiifn.'c. 
Thnc   is,  in   nivoi.inioi.,  adisturh.d   rathrr  than  a   |.fo. 
f.uind  slrt'i.,  n.i'  tlu'  reason  that  ivtlex  dislurhan.'.s  oltcii 
,,h,v  an   important   j-art    in   this   condition,  su.h   as   piii- 
woiiiis   in    th.'   roctuin,   iindipstc.l    foo.l    in   th.'   howi'ls, 
rlon.Mtr.l,  adh.n'iit,  nv   irritati'.l    pivpiuf,  ston.'    in   thc^ 
,,,^„,',l,,,  „,  ,„h1iu'  ix.it.n.rnt  .lurin.tr  th.'  .lay  wliuli  w..ul. 
,..uis..  th.'  .•hil.l  to  .hvani  an.l  h.'  r.'sth'ss.     Tin-  HU.-.'csstul 
tivatnunt   hv  sc.lativcs  scciiis  ids.,  t..  iM.int  t..  its  h.inir  a 
rcstU'ss  ratll.'r  than  a  j.rofoun.l  sU'cp.     My  own  holu't  is 
that  it  .l.)t's  not  dc'ia'ii.l  upon  an  aiavsthi'sia ;  .>n  the  oun- 


■•'■i^^^MMfVfHStilMP. 


».'*..  *»*iW***ftf»«-==^'    .>»ii*^'' 


208 


visi:.\si:s  OF  Tin:  i'J,.\nni'f!- 


I.  ;, 

■  iH 


■■"lit 


trarv,  T  liol.l  that  tl..-y  \\-r\  tlu-  -U'si.v  t..  uriiiat..,  aii.l  .i.ipt.v 
tlH.'l.la.l.l.T  uikI.t  til.-  sanu.  nu'.ital  .M.n.l.tu.M  ,n  whu'l. 
,l,,v  ini-ht  Nvalk  .,,•  talk  ii.  llu'ir  sl.^r--"''"  "  ''^  ''' 
non.ial  voluntary  art,  th-  .vsult  of  an  un.'u„M.,ous  .v.v- 

braliim.  ,  ,  , 

Y,i,^rMi:NT.-Mai.v  of  tlu-so  .•l.il.lrri,  ran  hv  .Min.l  l.y 
Htri.-t  attention  to  In-ioms  that  is,  nuv  as  to  tlu-ir  .lu>t. 
avohlin-  too  nuuh  .Irink  in  tlu-  lattn-  i^ut  ot  tlu-  .lay, 
,„„1  ..•uar.linir  a-ainst  ov.T-i.x.'it.'.nont  .)r  ox.TtH.ij  at  any 
tiuH."  'I'lH-v  shouM  not  hi'  alh.w.Ml  to  -..  t..  thv  .•uv.'s  .>r 
Wihl  West  shows  in  tlh'  .'ViM.in-.  Wh.-n  tluT.-  is  an 
,„llu.n.nt.  .■!.  i-at.'.l,  ov  irritahlo  pr.'im.v,  .■imnn.'isi..n  is 
not  onlv  justitiahl.',  hut  vwn  nooossary. 

Thi- "ivotuiu  shoul.l  hv  oxaiuiiu'.l  tor  ,.in-w<.nns;  in 
short,  in  this  .>on.lition,  as  in  all  ..thor  .liscasos,  raiytul 
in,,uirv  shoul.l  hr  n.a.U' int..  tlu- oti,.l..-y  hcf..ro  lu-tscrihing. 

Manv'of  thi-sc-  .-hihlri-n  rniuiiv  ,i,^om-ral  tonu-  tr.-atnu-nt, 
;,,„;  „i,n,u-,  .-(..l-liNvr  ..il,.t.-.,with  n,...U-rate  ..ut-.hmr 
,.x.-r.is.  an.l  .-han-.-  ..f  c-li.nat..  Tlu-  sju-.-ial  ivnie.ly 
that  ^.-.■ms  to  1h-  ..f  nu)st  use  in  my  han.ls  is  h.-11a(U)nna, 
•ihout  tivL-  .lr..i.s  of  the  tincture  jrivon  at  three  or  h.ur 
in  tlu-  afternoon  an.l  repeated  at  l.e.ltime.  When  this 
iUils,  1  have  oeeash.nally  sueeee.le.l  hy  .•onihinm.ir  the  hel- 
la.h.nna  with  tlui.l  extraet  of  erir-.t,  n^xv-xx,  an.l  I  have 
pometiiues  found  er.tcot  alone  to  answer  an  excellent  pur- 


nose. 


Tin.ture  of  hv.  sevainns,  with  or  without  spirit  ..f  nitrous 
ether,  has  heen'found  eiHeient  with  s.une  chihlreii ;  while 
\n  v.-rv  nerv.>us  children  hromi.le  .-..inhiiu-.l  with  chh.ral 
hv.lran-  has  sueeee.le.l,  showin.i;  that  in  those  eases,  at  least, 
theiH-  was  present  a  hypera-sthesia  rather  than  an  anscs- 
thesia.     Another  .-xi-el'lent  remedy  is  eodi-ine. 

If  thes.-  ehil.lren  are  watched,  it  will  he  found  that  most 
of  them  sleep  in  the  dorsal  p.)sitiou ;  and  it  is  while  lying 


m^ 


i:r4:T.JS-!iSS«*fc«<J<Hl«i'«»  •*«<""" 


^.-,«M(»i*«(<Ma«».^t&.''««**«w«"«'<»-'^«'*«*^^       -' 


1 


iTi-  IS  ail 
urision  is 

orins ;   in 
's,  carot'ul 
■escribing. 
:reatmont, 
'  out-door 
il   n'UK'dy 
i'lla<loniia, 
M  or  tour 
allien  tliis 
:i!j:  tho  bol- 
111(1  I  have 
olloiit  pur- 


EMiiHsis  yorrrnxA.  -09 

on  the  l.a.'k  that  tli  •  evacuation  takt's  placo.  A  means 
i.iiii.l..\v(l  l.v  many  mothers,  wl.i.li  often  provi's  cmra.'ious, 
is  to  tie  a"to\vel'alM.ut  the  i-liil.l  witli  tlie  knot  l)elnn(l, 
wliieh  wlien  lie  turns  on  his  haek  either  awakens  him  or 
causes  him  to  ehani^a'  his  position. 


18» 


tot' nitrons 
fell ;  while 
ith  chloral 
ics,  at  least, 
n  an  aujcs- 

il  that  most 
while  lying 


.■.!«*«a9?«sr"''««-fWB!!!«-»^' 


210 


DiAiiirn.s 


'M 


SBCTION   V. 


CIIATTKli   T. 


i 


DIAllETKS. 

IIHTOUY.— The  first  cU'i.r  .Irs.-npti-.n  of  a  case  ..f  .lia- 
lH.t<.s'nu.t  with  in  i.u..li.al  lit.rat.uv  is  in  tl.o  wr.tn.-s  o 
(Vl<u^      Uv  calls  attention  tc  pationts  who  .■..niplain  ot 
irn.at  weakness,  excessive  thirst,  cxtn  n.e  emaciation,  an,l 
tlu'  uassaiTc  of  lari;e  (,uantitios  of  urnu'. 

ArotirMis  is  crclitcl  wi^h  havin-  iirst  use.l  the  tern.  <h<- 
/.7..,  referrintr  to  the<lis..,se  as  follows:  '>  Diabetes  .s  a 
won.l Tfnl  atieetion,  not  verv  fre.inent  ainon-  men,  hem- 
n  n.eltinir  down  of  the  flesh  an.l  lin.hs  int..  nnne :  .  .  . 
the  patients  never  stop  makin.i,^  water,  hut  the  flow  ,s  ni- 
eessant  as  if  from  the  opening  of  a.iueclnets.  Calen  also 
makes  mention  of  the  disease. 

Little  or  no  advance  was  made  in  .lu-  knowledge  ot  the 
disease  until  the  time  of  Willis,  in  \m.  He  aserd.ed 
the  sweet  taste  and  smell  of  the  urine  to  the  presence  ot 
Ku.ar.  Soon  after  this  suggestion  hy  Will-,  sugar  was 
separated  from  diabetic  urine  by  chemical  analysis,  and 
all  doubt  was  thus  removed. 

It  is  about  one  hundred  years  since  KoUo  observed  that 
vegetable  foo.l  increase.l  the  .pumtity  of  sugar  m  the  urine 
.,ud  in  conseuuence  advocate.l  a  purely  animal  diet  >o 
until  1823  was  it  discovere<l  by  TuMlemann  and  (.melin 
that  starchv  food  was  converted  into  sugar  during  the 
process  uf  digestion.     Soon  after  this  sugar  was  demon- 


mi 


— :ii»ofiR;3nr!?^""-*p****ttww 


3'»it->i.-««'"S 


AMi 


DIMiKTKS  MF.iJ.nrs. 


•211 


\\  ritiiiirs  of 
'()mi»lain  of 
L'iutioii,  luul 

Ik'  torni  '/'"- 
I'liilu'toH  is  il 
mi'ii,  boiiig 
uriin' :  .  .  . 
o  tlow  is  in- 
GaK'ii  also 

Ic'dijo  of  the 
He  userilH'd 
>  presenee  ot 
s,  suu;ar  was 
iiiialysis,  and 

observed  that 
r  in  the  urine 
nil  diet.  Xi»t 
and  (Imelin 
ir  dnriiiu  the 
r  was  denion- 


stratol  t..  he  i.ivsc.nt  in  the  hloo.l.  Claude  IVrnanl  was 
tlu-  first  to  .h-in.Mistrate  tliat  sn.irar  is  ••onstantly  i>resent  n. 
,1,.,  l.lo.Ml  of  th..  ri-l.t  shle  of  the  heart,  while  it  is  almost 
...itirrlv  absent  on  the  h'ft  si.le,  an.l  that  it  ent.rs  the 
inn.ri.M-  eava  by  the  hepatie  win.  He  also  foun.l  but  a 
trare  of  sn.srur  in   the  portal  vein,  thi  .wn.-  that  the 

livrr  is  thf  irreat  snirar-iinxlininir  orti, 

IJrrnar.l  Vnrtln'r   tau-ht  that   the  liver  ha.l  two  su-ar 
nui.ti..ns,— nanuOv,tlmt.)fe..nvertinKsujiarint.)!:lye.^iXei., 

or  its  jrly.M.ironetie  function,  and  that  of  convertin.i,'  .srly- 
coiTon  Tnt..  suu-ar,  or  its  .-lyeojrcnie  funetion.  liernard's 
tliwries  have  never  l)een  unanimously  ueeepted  by  physio- 
loiXieal  rhemists. 

We  usually  niaki-  a  division  of  diabetes  into  two  classes, 
— iliahetes  niellitus  and  diabetes  insipidus. 


ClIAPTEK   IT. 

DIABETES      MELUTUS      (MELMTUKIA  —  ULYCOSURIA — 

olucosimua). 

DiAWETES  MEi.LiTUS  is  a  disease  whose  I'tiolojry  and  pa- 
thology arc  obscure,  hut  whose  pathognomonic  symptom 
is  the  presence  of  sujrar  in  the  urine. 

Etiolo(JY.— While  it  is  impossible  to  state  the  exact 
cause  of  diabetes  mellitns,  we  have  learned  from  observa- 
tion numy  of  the  conditions  which  seem  to  act  as  etiolo<?ical 

factors. 

(7/,,,„/,.,_This  has  probably  little  or  nothmg  to  do  witli 
the  production  of  diabetes,  althouj^di  it  is  often  stated  that 
iiussia,  IJrazil,  and  the  Antilles  possess  a  peculiar  exemp- 
tion from  this  disease.     1  imagine,  however,  that  in  coun- 


— J 


IVl 


i)i.\iii:ri:s 


,,i..  -i.arsrlv  sHtl.-l  wn.l  with  t;.w  ,<u..H.ul  mumk  tl..  intW'- 

:::n:.l...i.;n,.o..t..i ;-'-;-•';-•;;:;  ;;;^ 

.!,.,,:,rul  .x.nm..tio,.  of  th..  un.H..     ^^ '■/'',  ^""^^1 

,,,i.ns,.t-urLas,luM'l>vsi.iaMswl.odooho.  ,'.•u.' 
,  ,,,..  eitics,  nor  anM...nntry-i-.,.U-,  as  a  ruK..  s..  ,..;.   Ml;t 
:r.onsul,in,  a  ,,h>>i.ian  as  an-  .l.oso  wl.o  .vswl.  w. 


Cltll'S. 


rUn.ato,  thoroior.,  is  n..t  an  .nolo.i..al   ta.tor  of  any 
jd'oniinciu'i'. 

Tlu'  sanu'  niav  Ik-  said  of  seasons.  ,       ,      •  i 

1/ ._M.un\vnn.rson.lialK.t.ssta...thattho.I..v,sh 

,,,„,   .s   ,,ar,i.ularly   liaUK-  to   tl.is  d.s.as.  an.l   tl^at^thc 
African    nuv   is    i.o.'uliarly   i'xoini.t 


Xi-itlior   of  tlu'so 


;  .ts   is   n..;..t.       In  llu.  c-aso  of  tlu.   HoW-    ins 

V  to  .lialK.t.s  is  no  .lonbt  tlu-  r.snlt  ot  Ins  »>a..Us, 

;.,ion,H..ratlu.r,lKn.ofl.isnu.;.nl....a^^ 

tlH.   \fri.an,tlu..va,vn.Mlatat<.Nvan-anttho  assert  on  ot 

II;:  ;.l,.,ion,  an.n.is  haUits  a.v  n..t  sn..h  as  wonl.l  tonn 

ii  uri'tHsiiosinir  cansi'.  ,.  ,    ^      ,i  ,., 

'.V,  ,._lln  adults  nn.U.s  aro  n>o.v  sul.joot  to  Oabot.s  than 
IV.nalrs.     In  .hiM.rn  sox  is  not  an  i'tiolo-u..!    a.t..r 

'  -N-'^-  -  ^'>^^''''l'*-  The  a,.-s  that  inrn.sh  th. 
Ur^;L  pcnvnta^.  of  .as^s  aro,  in  n.al.s,  tnun  th.rty  to 
.ixu  voars,  and  in  f.nnd.s  tn.n,  Wn  to  tlnrty  years 
■  ■//;/,;/. -Ihd.its  of  lifo  an<l  oc.ui.ation,  no  douht,  pla^ 
^,  ,,„t  part  in  the  ,.rodiu-tion  of  tins  d.s.aso  1 
^  .\vill-o.tahlish.d  ta..t  that  se.l.ntary  hah.ts  and  lu^h 
WU  ,m.dis,os.  to   diahetes;   and    M.I.V.   that   th^^^ 

Uvo  nu  tors  a.'-ount  for  th.  nnusual  proportion  ot  llchr... 
i„  „„,  i„...  ..iti.s  who  snflVr  from  this  .on.ht.on 

;;;;../;/;-I)iah.t.s  is  not  a  w.ll-n.arkcd  hcnnhtary  <hs^ 
,,.,..  althou-h  w.  d..  nu-vt  with  casos  ,n  whuh  th.  tanul> 
history  pohits  stron.udy  to  lH.rc..litary  pr.disi.osUion. 


'^i^ 


^;  _.  .  ,^^(gj^eg!.i!!SrsT-:--^'^l»#-*»=*^'»*®'^^ 


^^j„-;^?«»Mh**.«-*arti««»*.«a^^ 


DIMiKTES  Miii.i.rns 


m 


.  tlif  iiitVc- 
tfd  to  link 
kiiiiw  tliat 
icir  I'Xiiiiii- 
II'  iinutifi' 
,  so  jtroiiil't 
o  R'siik'  in 

•tor  of  any 


tlu'  .Iiwisli 
1(1  lliat  till- 
LT  ol'  tlu'so 
tlolm-w,  \\\^ 
f  liis  liiil'its, 
\v  in  that  of 
ansertion  of 
wonM  form 

liiilu'ti's  llum 
I  fa<-tor. 

fnrnisli  tho 
oTii  thirty  to 

years. 

)  (lonlit,  i>lay 
\  (lisiiisi-.  It 
lits  antl  lii.irli 
/t'  that  tlu'so 
n  of  Ilohrews 
ition. 

uToditary  <lis- 
it-h  the  family 
)osition. 


Pn<i)iitiivfi. — It  is  not  luiroiniiioii  t(»  \\\u\  suirar  in  tlu' 
nrinr  .hirin.ic  prt'iriiancy,  nor  is  ii  iiiuisiial  to  liiul  lli<- 
sMirar  tlisappfar  after  hiltor.  wiilioiit  trcatnunt. 

Snirar  oft»'n  api^i-ars  trnqiorarily  in  tlir  nrinc  after  an 
exeessivi!  (|nantity  ot"  siii^ar  has  lieen  taken  into  tlie  sys- 
tem, after  l)lo\vs  or  slioeks,  after  i.eriods  of  exeessive  stiuly 
or  <if  stroiiix  mental  emotion,  and  after  epileptic  tits. 

Dialietes  attacks  two  very  ditferent  types,— namely,  the 
stont,  oheso,  mns.'iilar  person  of  ijonty  hahit  and  tin-  thin, 
nervous,  iienralt^ie  suhjei-f. 

There  are  many  snhstanees  which  when  taken  into  the 
sv-tem  in  excess  prodnei-  diahetes,  at  least  tcmpoi'arily  : 
for  instaiH'e,  hy«lrocyanic  acid,  earhoiiie  acid  u'as,  nior- 
plilne,  mercury,  etc. 

I'.\Tiloi.<MiY.— We  have  already  ohserved  that  tiie  pa- 
tholo--y  of  diahetes  is  ohscure.  While  it  is  a  fact  that  in 
no  ca-^i"  .)f  death  from  diahetes  is  every  or,i,'an  in  the  hody 
found  to  he  normal,  it  is  e(pnilly  true  that  there  is  no  one 
or-'an  that  is  always  found  in  a  patholoj!;ieal  condition. 

When  a  i)ost-mortom  does  reveal  a  patholo,t,'i<-al  condi- 
tion of  an  oi\tran  if  is  impossihle  to  say  whether  tlie  dis- 
eased  organ  Caused  the  suirar  to  appear  in  the  urine  or 
whether  the  su,«rar  in  the  hlood  produced  tlu'  oru-aiiic 
ehantri'.  In  other  words,  there  is  no  patholo<;ical  anatomy 
characteristic  of  diahetes, 

f/n-ir.—\\  is  not  infreipient  to  find  the  liver  (piite 
nonnal  in  api.earance.  Ofteiier,  however,  it  is  eidaru'c'l 
and  hvpenvmic,  the  capillaries  heinir  niuch  distended  and 
the  hepatic  cells  swollen.  (Occasionally  there  is  an  in- 
<ipient  cirrhosis  or  a  fatty  de.irem-ration  ;  hut  there  is  no 
evidence  that  the  cirrhosis  is  the  result  of  tlu-  suirar. 

P,mrvi'ii!i.—\X  is  douhtful  whetluT  any  one  ortan  is 
more  often  tound  diseased  in  diahetes  than  the  ].anerea8. 
In  one  ease  it  nniy  he  hypertroi.hied,  in  another  it  may 


««!M«a>it»4w 


mmmm^ 


V 


^U 


214  nunKTHs. 

,,^.^,,,,    ,,■„,.,  ......vstir.     (•on.Tc.tions..l.stnu-Hn^r,lu..ln.t 

,,,vM.'..MonM.K  ;u.l  tattv  a.u-.HTation  .s  not  a  ran.  .■..,.. 

'*''i;":,,_Tlu.s.  organs  an.  otWn  t;MUwl  ais^^^^^^^ 
,,,t.s;tlK.    patl.ol..^i.-.l    .•oM.liti..Ms    lH.i..,r    .;.n.,n.   l.ron- 
,.,.iti,  til.n:nsi.l>tlMsis,o,-tnlK.n.ul..s,s.     ^M"  ^  '  ^       ; 

'      X     lu.  ain..t   result  onho  su^a.- in  tlu.  1   00.1    .MS 
;l;;s;i;.le  that  m  ,h.se  ease,  tho  sugar  l>as  ,ro.lu.....l  the 

'^'^;^",_TlH.  spU-cn  has  lu.-n  to.uul  hy,K.rtro,.hh.a  in 

M.nu-  rases  an<l  atroi'lii''^  \n  <»tlu'rs. 

■    ';;';,/,,,WlMu.kianovsar.vc.ryot-ton,hutnotn.vam.l   , 

,..,a,...;i.  Th..nhn-gc.nu.nt,wh.n,.vsom,.snuMv  ,k.y 
,„  ,,;,lu.  to  hyiK.n.nna  than  t.>  organic  .hseas..  Lh.l  h 
Urts  tlu.t   th'   cr'tl-l-H'-n  <.t-  Il.nk.'s  lo..,.  )s  ahva  .  a.- 

;,.„.,nu.a  in  aialK.,.s,ana  that  it  Uaglv.>gc.n..  .^^^^^^^ 
•      ..   .  .  .,,...  ;.    .1,..  ..roiouhisni  ol  tho  .i'lls  al\va\s  con- 


oration;   that  is,  the  i.rotoi.lasni 


„•„,  .,vc<....n.  It  is  l.rohahU>  that  there  is  n.>  spec  k 
..U,..,,.nieae.eneratn>nJ>ut  that  the  hypcraMma  ..t  the 
kianev  l.roauces  a  celluhu-  nntritive  necrosis  or  .K-ene.a- 
r,..n  a'na  that  the  cells  ahsorh  glycogen  from  the  ur.ne 

When  tnh.Uar  or  intertnhnlar  nephritis  is  present,  it  is 
i,n,...ssihle  to  aetennine  its  relation  to  .liahetes. 

V/</.r.-The  Ma.l.ler  is  ..ften  greatly  hypertrophiea, 

the  result  of  functh.nal  activity.     The  hypertn.phy  may 

.ither  concentric  or  excentric,  the  former  oecurnng 

:,:,    ,,,    .,,ar    proauces    hypera-sthesia    am     trcMuent 

l.ncturition;    the    latter,  xvhen   the   ..uantity  ot    unne  ,. 

verv  irrcat  aiul  hypera-sthesia  is  not  present. 

.;,;,,,./.-The  appearance  of  the   sto,na<-h   ana    intes- 
tines on    post-mortem    furnishes  no  explanation  ot   the 
.      .nous    appetite    ana    insatiable    thirst    so    otten    <-..m- 
laot^hyona,  perhaps,  sonie  enlargement  or  hyper- 


«,*«:./J»».^«i«-*»>«l«5a*^'-i*^T»«»»-«^^ 


EIBSfi.ii 


/./.i/!/;r/-:.v  mki.iatvs. 


•215 


the  tlilft 
rare  iini- 

•d  ill  tliil- 
iiic   Itroii- 

.    tlllTl'     H 

I'litf    tluit 
IikmI,  it  is 

IucvmI    till' 

dl.liird    ill 

iivariiiltly, 
unT  likoly 
.     Klirlich 
always  tUv 
iiir  (k'treii- 
Iways  cou- 
nt) sporitic 
iiiiii  of  tlio 
•  (K'jiviK'ra- 
10  uriiK'. 
ri'siMit,  it  is 
s. 

iiTti'()phii'<l, 
trophy  may 
r  ocfurrinir 
1(1  iVotiiii'iit 
of  uriiR'  is 

ai\(l   iiit.'s- 

tiou   of  the 

ofti'ii    coui- 

nt  or  hyiicr- 


trophy  of  tin.  stoM.a.h  whhh  is  th.  .vsult  of  thr  mvossary 

fuiiftioiial  activity. 

/</,„./ -The  hloo.l  n..nnally  contains  a  small  amount 
of  suuar,  an.l  it  Is  only  wh.-n  this  .,nantity  has  l.ccn  cu- 
.i.lcral.lv  incrcas,..!  that  wc  .Icsi.^inatc  the  con.l.tu...  as 
..Ivka.mia   an.l   the  conso.pUM.t   presence  ot  sn-ar   in   tl.e 

urine  as  glycosuria. 

Symptoms.— There  are  no  suhjcctive  symptoms  patl.oif- 
nomonic  of  .liahetes,  ami  there  is  hut  one  ohjcct.ve  symp- 

to,„,_namelv,  ex<-ess  of  siit^ar  in  the  hi I  as  evn leme.l 

,,v  its  appeanu.ce  in  the  urine.  There  are  teW  pa  , cuts, 
,;.„vever,  who  ,h.  not  complain  of  excessive  wc-akness, 
muscular  dehility  hein.-r  sehh.m  alwut. 

rw.r-As  su-ar  in  the  urine  is  the  patl.o.miomomc 
.vmptom  of  .liahetes,  it  will  he  well  first  to  consnler  the 
nVniptoms    exhihite.l    hy    the    urinary    orj^ans.        a  lenh. 
.;.iaom  complain  of  pain  over  the  ix-ion  ot  the  knlne^s 
,,„,   ,.nen   experience  a  dull,  heavy,  dra^^m^   sensa    o 
ahout  the  loins.     Xor  (h.  they  often  complain  ot  pain    n 
the  hladder.     Occasionally  they  exhih.t  .n-at  •••ntahil 
^,,.^,,^,  l,ladder,the   hypenesthesia   heu.LM.o  douht     p.o- 

.lueed  hvthe  irritatin-  .p"^l't.V  -'"  <''^'  "'"'^■-  /'^^  *'"'.'' 
there  will  he  a  catarrhal  cystitis,  with  some  pain  on  m.c- 
»„,ition.  rn  other  cases  there  will  he  well-marked  hyper- 
troithv  of  the  hladder.  .     .    , ,  i 

;),.;asionallv  we  tind  phimosis,  with  an  irn  ah  e  ami 
.x.oriated  condition  of  the  prepuce,  while  m  the  tcmialt 
,;,„,Uus  vulva,  is  often  an  extremely  unnoyu.iT  symptom 
Diahetic  patients  usually  void  an  <;'^^^-';r  'l'^^  '^-y; 
,.,i,H.,  some  micturatii,,^  tVe.piently,  heii.i,  .listurhed  otten 
at  ni.'ht,  ami  makin.ir  in  the  twenty-fonr  hours  a  -alh.n  or 
more  of  liirht-trreenish  cr  straw-colored  urine. 

The  amount,  of  course,  varies  with  the  amount  o   huuul 
ingested,  although  some  experimenters  maintain  that  the 


216 


i>i.\iii:ti:x. 


>\ 


ij 


'  I 


(it 
til. 


„,in.-  voi.l..4  is  on.n  in  .x-.-s  of  tl,.-  .,nantity  ..f  tl.u.l 
tiiloii  int..  til.' stoiiia.li. 

.,.,,.,  ,,, .i.l  ,l.or,..iu,.  of  tlu.  ll.M.l  Iro.M   .1...  MlM.u.Mt.n 
,„„,  i.v  ,1...  l,loo.l-v.ss,.l.  tak.s  l.la.v  in  a.v..nl......  wUl. 

U.ki.nui.  J.l.vsi.al  law  of  ohuhwih.  , 

•n..,  .uin.  l.a.  a  swvvl,  sirk-nintr  o.Jor  ';>"; '^  f^^'^;''^^  ' 
H.,..  Its  s,..-if..  .M^avity  ran..>  f.o.u  lu->..  to  K.-.O. 
,;.:;„:.  ^...H-raUv  al.out  lu:;o.  Th.  an.ou.^t  ot  su^ar 
vuric^fron.  two  to  ..i,..  ,kt  o.^..  or  fn.,u  two  or  timv 
enm,^  to  lw..„tv-fnv  Lrrains  to  th.  o.,mo.  \\  I.«U-  th| 
;.n.mnt  of  una  to  llu.  onu.v  of  nri.u.  is  Msaallv  a.m.as,..  1, 

,,,,.,,,,, i.v  ..m.t..l  in  twvntsMour  In.urs  mua.ns  a -on 
th,sanM-as"inl..altl..      I,  is  onl.v  in  .as.s  wIh.v  no  tl.u^t 
is  ,x,K..irnr...l   that    thr  M":"'tity  ..f  urin.  l.ass.<l  is  lens 

"'/;;'!^I-!!;!_TI...  n.ajority  of  .lialKtir  i-ati.nts  l>ay.  rav.n- 
.,..ap,..ti..s,a..on.,.ani..ai.yinsatial.l.- thirst.  lh.y|o,n- 
,,lain  of  a  ,.an-h..a  ana  .Iry  ,n..nth  ana  t In-oat,  ana  a,. 
Lontinnally' ...avin,  n.on.  a..ink.  ;nH' '..;»!., -P-aly- 
vou,..'  iKTsons.  .hvay  rapiaiy,  own.-r  I-fohahly  to  an  .uul 
V,n„:,.tatiouof  thoso.Mvtionsof  th..  ni..uth. 

,„  ,.uM,v  ras.s,  notwithstanain.u^  tin-  .ij.vat  uniount  ot 
tinia  ana  f.u.a  takH.  into  the  stonuuau  the.  ,.atu.nts  n.m- 

,.l,i„   v.TV   litth-  of  inai.^stion;   whih-  otlu-rs,  wh..  take 
,ut  littl.'tooa,  olh.n  vo,nit,  at.l  aro  ..n.stantly  .h.t,vssc.a 

,,  ,,,s  in  the  stonuuh  ana  how.ls,  tats  .s,K.y,al  v  h.u^ 
.linhuh  for  tlu.n.  to  ai.u.st.  Thisn.nait.oti  nn,.a.t  w.l  ho 
anti.il.at.a  fron.  th.  ta.t  that  aiahoti.  i-atunts  aro  so  ott.n 
„.,.  suhj.vts  of  a  ,.atholo,./ual  ...naition  ol  the-  l.an.-rca. 

""V^Lr,    0,v/....-IVyona  tho   w.ak    p.a^.    tVo.n   a 
,.,.,u.rat.a    ana   atro,hi.a   -...aiti..,.  o.    tho  h.JJ.     nn. 
.lih.tation  of  th.  .H.rohral  v.ss.ls,  thotv  ar.  no  .t„k,ng  or 
von^tant  svtnpton.s  .on.u.-toa  with  the  c-urulatu.n. 


■ '^'^Nwmf-^a  .^.v«t^>*«««*'^««*««^^ 


DIAHr/rHS  MI'JJJTI'S. 


•217 


<.r  tiui<i 

iiiu'iiliiry 
iu«'  with 

s\vt'«'tisli 
to   in.-)!). 

i)t'    siiLi'ar 

ol'   llll'i'i' 
\'W\W    tlH' 

ii.'(  ivasctl, 
liurt  alioiit 
.  Ill)  tliii^t 
111  is  K'ss 

\w  ravi'ii- 
riu'vcom- 
,  and  an- 
l»f<ially  in 
to  an  tici'l 

miount  of 

ii'iits  I'oiii- 

wlii)  tai<»' 

distri'ssod 

ially  I  toil  lie 

irlit  WH'U  \ni 

iro  so  ot'ti'U 
(.'  ^lain'roas 

Isi'  fVoiii  u 
Ill-art  and 
striking  or 

tioti. 


^^,„„/,,__Nh,nv  .lial.ti-  i-atiH.ts  .li*'  ..!'  l-l.tJiisis    .illuT 
tulKT.nlar  or  til'.rous,  wl.il.  a  la.-,  nun.lur  a,v  ll..  sub- 
iertH  of  .-hroni.-  l.nMi.l.itis.     Thuv  is  ....tlung  rliarartor- 
isti.-  in  the  pulniouarv  syMiptoins  of  .lial..ti.-  patu-nts 

\ar.n>s   S>islrm.-\\'U\\v    Ik-u.Iu.-Ik.    is    n..t    a    c-o.istant 
.vnn.ton.,  it'  is    l.v  no  nu-at.s    infmi.wnt,  sonu-    i-atu-nts 
i;,i„„  th.  sulMc-Hs  of  intcnsi-  l..-n,i.fania.      Nm.al-ia  ot 
„,lu.r  n.TV.s  is  oft.n  a  .aus.  of  .list.vs>,  an.l  .li//..nrss  an.l 
vcrti-o  aiv  orcasiunallv  tr..ul.Usoni..     Many  i-atu-nts  l.v- 
c-o,n  ".Nt.H-.n.lv  irritul.io,  whik-  ..tlnTs  an-  given  to  in.lan- 
,.h„r.a.     Tin'  .li/-//nu'ss,  VL-rtig..,  inital.ility,  or  nulanHiolia 
eouM  be  at.tiripatr.l  fro.n  the  fa.'t  that   pathologteal  eon- 
.litiuns  ..f  the  eoiehi-al  eir.'nlation  an-  otien  presc-nt 

,s7,;,,._Thi'  skin  is  often  vei-y  dry,  harsh,  an.l  sealy,  an.l 
seldom  is  there  mueh  perspiration. 

In  ol.ler  persons,  carhutxles  sh.  .nld  always  he  .ons.de.e.l 
^,„  i,„,i..ation  for  an  examination  of  the  .nine  tor  sngar, 
as  in  a  lar-e  n.unh.r  of  eases  the  two  are  assoen.ted. 

The  nn.st  fre.pient  skin  .Hseasc-  in  female  pat.en  s  how- 
,v.r  is  the  ee/.enia  that  results  Iron,  the  ,.r.,ntns  lah..l.s. 
The  exeoriations  ahont  the  vtdva  aiid  thighs  are  cxeessively 
,,nn..ving  and  exeeedingly  intraetahle.  ,.,...,, 

K;ze...as  appear  on  other  po.-t,....s  ot  the  l.od.N,  otte, 
disappeariniT  as  the  .ugar  din.inishes  u.nler  treatn.ent,  a..d 
,,,,.urrinir  with  the  reai.pearanee  of  the  sugar. 

( )....asionally  in  elderly  gouty  patients  there  is  gangrene, 
ros.mhliuir  senile  gangrene  in  its  eourse.  .  ^    ,.  ,    , 

Zona...r  herpes  zoster,  is  often  assoenited  wUl.  dial.etes, 
ospeeiallv  in  the  gouty.  Whether  or  n<.t  there  ,s  any  re- 
laiion  between  the  tw<.  it  is  ditHeult  to  say,  as  we  otten 
havi-  herpes  in  the  g.mty  witlu.nt  st.gar. 

.sv,//,/._('ataraet  and  amblyopia  are  fre.iuently  associa  e. 
with  a  diabetie  e.mdition.     hon.e  at.thors  nuuntain  that 
there  is  an  impairment  of  the  eihary  musele. 


■idAliS^iv 


.WW«W|ff«»W-'"' 


•««■■ 


21 H 


i)iMii:ri:s. 


I 


i      ••! 


•''^    I 


Thf  MMlniia  wlii.l.  is  riv.in.Mlly  ).ivs».|it  is  pmlMLlv  tlu- 
result  of  il.-l.iiilv,  iis  in  ..tli.r  loniis  ..f  ainvniiii. 

KiiM.i,iti..M  is  sum.tiiii.s  .Mivm.-,  im.l  ...•.urs  ir.M..  niil.v 
i„  tl.n...  patiiiits  vvliu  a.v  n.i.n.l-i.'  or  i-l.ll.isi.-al  an.l  ..t' 
snaiv  l.al.it,  an.l  in  wl-.u.  tl..^  ai-pi-tit.^  is  raNvnuus  an.l 
•  h..  tl.iist  v.TV  u'lvut.  In  oili.T  ras,s.  in.t  a.v..Mii.aiMf.l  l.y 
,.,„.„.•,.„•„,„.  ,1,;,,.,.  nuiy  !»■  initluT  incmiM'.l  api-'Ht^'  "">• 

I'Xt't'ssivc  lliii'>t. 

Tlirti'niiKTatmv  is  usually  siil.n..rnial,  lli.'  paiiiiit  ..tim 

iM.nii.lainiML'  «'|'  iot-lini;  diilly. 

.l,,/„/ur„/;'/.— iVmrs  first  ..1.s,tv.m1  .lialK-tic  touia.  At- 
t,.nti..n  was  .lin'itnl  t..  lli.'  a.H..m-liki'  sincll  of  tli»-  unuo 
in  IS.M.  an.l  it  was  sui-pos,.,!  to  I..-  .In.-  I..  tl.»'  pivs.!...'  ot 
ar.ton..  in  tl...  LL-.l.  Tlu-  syn.pt.mis  usually  .Ks.f.l.... I 
as  in.li.atin.ir  a.'.l.'ua'inia  liv.nniitly  inanif.st  tlinnsolvert 
oitli.T  tlir.>uirli.>iil  .•!•  lat.'  in  tli.'  rours.'  of  tli.'  .lisfas*-. 

Til.'  syinptonis  vary.  Kut   an-  <.t't*-n  nniiiili'st.'.l  in  three 
Uistinrt'statr^'s.— nan'.rly,  a  sta-.'   ..f  ..x.itiinu.t,  ..n.'  of 
iTivat   r.stlissiuss,  uiK'asiniss,  an.l  .lyspnoa,  an.l  .ui.'  ..t 
Tonia.      Durin,--  tlics.'  sta.uvs  tlio  su.irar  is  loiin.l  in  nnwli 
small,  r  amount  in  tli.'  uriuf,  or  may  I'ViMi  Ik-  ahsmt.     It 
was  f.ir  this  n-asoii  that  actom'  was  sui.im.sim1  t..  a..uinu- 
jatf  ill  th.'  l.l.M.'l.  wK.iu.'  till-  iiaino  a.-ctoiiuMnia.     It  has 
Ills.,  h.vn   i-n.jM.sf.l  io  .U-si-natc  tlu-  r..ii.lith.n  as  hypc-r- 
.rlyka'inia.     'I'll*'  .onsiMisiis  ..f  ..i.ini..u  of  i-\p.'niiicntcrs 
si'niis  at   i-ivs.-nt  t..  !..•  that  a.vt..m'  is  thi>  |.ro,lu.t  ..f  the 
UTiiu'iitation  .>f  trrapi-  suirar. 

'I'h.'  svmi.t<.ms  in  many  cases  are  similar  to  tln.se  ot 
s..-calK'.l"  ura'ini.-  i.oisoniii.iT :  the  sta,iie  of  ex.-iteiiient  in 
the  latter  is  ni..n-  lik.  ly  t..  h.-  a.'...mi.anie.l  hy  .•onvulsive 
eontraetioiis  ..f  th  •  mns.les,  while  in  the  toiiner  (aeeton- 
ieiiiia)  it  manifests  itself  hy  .irreat  .lis.|uietu.le,  with  in- 
e<.lieienee  an.l  iii.listin.tnes.  ..f  speeeh,  fre-iueiitly  iu- 
tersperse.l  with  atta.ks  ..f  .lyspn.ea,  remiu.ling  one  ut 


-!sr:r:r^:sj?>3srrasr 


^g~~gjnK^^JJ|S£*"^^*'fl.*5«-J 


DiMthriT.x  MHi.t.irrs. 


2H» 


Ml 


IV    till' 


ItflHl'llllV 
ill  illlil  <>l 
||iill>    il)l*l 

jiiii'iol  l>y 

"U'llt  ofU'll 

Illlil.     At- 
tlic  uriiu- 

•CSl'llCt'    1)1 
(ItMl'illt'tl 

luiiisi'lvert 
isi'iisf. 
(I  ill  tlirci- 
it,   out'    ot" 

111     dlU'     ot" 

il  ill  iiiiK'li 

lllSCIlt.         It 

II  iiiciumi- 
iii.  It  lias 
I  iis  liypor- 
ciiiiiciiters 
luct  of  till' 

to  tliosi-  of 

•iti'iiu'iit  in 

foiivulsivi' 

llT   (ilCl'totl- 

t',  with  iii- 
mu'iitly  in- 
iii;  uiK'   of 


.,,,,i,..  i.,h,i...     Ki,n.llvtl..',.ati.ut.inkHintoa.oniato.. 

..on.litioii,  ott.M  .Ivini:  in  a  ti'u  I'.'".-.  

To-uiii  .1...  th.n.  tlirn.  mv  Ivvn  .li>l»i.t   .  l..>  .  -  ot 
,      i        1  O, h.s.will.on...l..l..'l'l'V>"':'"-l""'; 

, „M.i«i..M':--  'I-'  I"-  ■""  ""  I"".-;:'- ."""-,•  •■",.' 

,,il  ;:,:..,„'•,.„.  >!..  .,ma.  l...,-,,,-..  ,..v«.ril.u,,  1...-  1- 

'■";;,:,„.„,|v  ■„  will  1...  r.mn.l  1"  l".v,.  „  .1 Hi,.  :.n,vl,v  ,.f 

I      -1  .^l^^■.v^  I'MIIII   lU'   t   U'   UlUlf  \\ll«M 

,i„„»  nm.v  1...  ,.r.«-"t,  ...■  .nay  ''.'^  "I    ■'•,',„,  ,,,,,„„,, 
K,m..ii..i"..  i»  utUn  thf  i.r,mn..L'.it  I...IUK, 


oxtrt'iut'. 


220 


/)/  I///-77V 


f 


I 


•:  i! 


l.„„„N..m.-.— Tl.r  |.n.iriiM.'H  .U-|.rn.lK  irn-utly  upon  tli.- 

„,r,.  of  ll.r  iMli.i.i  un.l  III.'  fnT.l.m.  fV... mpli.  i.ti.-,,.. 

"Wr  iMii'l  alwav-  Im-  LrM.ir.l.d  in  oiir  pL.-m.-is  it- 
,.|.,|,i,i,.  l.iun.l.ili..  pii.i.inoi.i;..  .arl.ui.rl.'s  lmi.-ivu.'. 
„..,,l„iti..  nr  .Tivl.n.l   in.,. I.I.'  n.i.v  -i.iMiv.i.r.  ..,•  il,r  .•>...■ 

,11.1  ill  infinity.  .  ,,      ,         .i 

Tl.r  vuuu-.r  tl..'  palirnt.  tli.-  iimiv  r:i|.i.llv  .lu.s  tlir 
.|i-..„..."iiii.  it.  .•..i.iM-..l.il.l.vM  aii.l  Vullll-ll.ll.lt-  Mitrl. 
.ivi.i-  in  a  f.-vv  iiiniitlis,  wl.ilo  in  .•l.l.rlv  pru,.|..  i.  Iiv,,ii.iitly 
j" n,.s    .limiiir.  M.-ar    l..i>''-'   .••.n^lantlv   f..mi.l    in    tlir 

'ritl-MMKM'.-iJi'lolV  .■ulllllinirini;  tl..'  t  IVi.t  lll.'llt  n\  il 
,,i,,,,,,i,  ,,„•„,„,.  it  nilll..'U.lllnrnst..r;,!ltu,i,.ll.l  that 
w..  kn..w  littl.'  ..r  notliin-  -f  tlu'  ..tiolu-v  ul  ll..'  -Iisras.-, 
„„.l  ,!,;„  vv..  Iiiiv.'  Imtii  iinal.l.'  t..  .lis.  ..v.t  its  i.atl...I..,-rv: 
,1,;,,  i.  u..  I.av.'  l.......  uni.l.!.'  to  .>ti.l.lisl.  tl..'  la  't  tl.iit  any 

„. .-'an  is  inva.ial.ly  lo.ui.l  in  a  i.;.tl.nl.../i.al  .o.i.l.th.n. 

\l  til.'  >aiii.'  tin..-  \v»-  must  .•.'iiii'iiil..'-  that  it  is  s.'l.l..ni 
,|,i„  ..„„.'  .....'  ..r  i«i"'>'  '"•.^■'"•^  "'■•■  ""'  '"  "  1""1'"'".-'"'"1 
,„,„,•„•„,„.  Tl.is  l..'in,ir  tl.v  -as.',  an.l  tl..'iv  !.'•'..,-  in. 
si....'iti.'  to.'  .r.alut.'s.  w.'  ni.ist  m'.in.'iK'  ..ursclvi's  I..  ti'i'Ut- 

iU""  s\  llllitolll"  olilv. 

A>  a    niatt.'i'  ..t'  .'onv.ni.'nr...  tli.'    ti'.'atnii-nt    may  1k' 
.livi.U'.l  int..  l.Vtfii'ni-,  .lii't.'ti.'.  an.l  ni.'.li.inal.     Of  tli.'M', 
it  is  .ri'in-i-allv  stat.'.l  l.y  a..tl....'s  that  tl..'  .li.'t.t..' is  l.y  lar 

tin-  n...st  ini'iM.i'tant.     Tl  is.  l...u -vvi',  is  tl..-  fa.t  ....ly  in 

n.-a.-.l  to  tl..-  ti'.'atn.i'nl  ..f  tin'  i.atlio,i:i..'in..ni.'  syinpt...... 

— iianulv,  til.'  irly<'.>snria. 

//,^,//,;,;,,_As  .lialK-ti.'  pati.'i.ts  have  nsnally  a  s.il.- 
....v.i.al  t.'n.i..'nit.u'.-,  .'l.ill  i-asily.  ami  .'...ni.lain  ..f  .'oM,  it 
is  i.upo,tant  to  l....k  well  to  tl.i-ir  .L.tliin-.  as  w.ll  as  t.. 
tli.'if  atmos|.l..-ri(' surr...imlin,-rs. 

Sri,<l  th.-n.  t..  a  wai-n.  .'limat.'.  wl..'.'.-  i.os>.l.i.-.  an.l 
alvvavs  .liH-ss  tl..'.ii  in  lla...ul.      V.-n  will  liml   that   many 


■^> 


-Mi 


ry-;.,.  .     j^.z..0^i-",^-^M 


f;x'rfc.i)SKt;'^%i»'''' 


r^iMirrrs  w//.//rrv 


mm  I 


|mUI    t1l(> 
It'll. III*. 

lO-ir*,     UH 

iiiiiri'<'i>«'. 

llir   I'llM- 

lilies  till* 
Its  oftt'll 
■ii|iU'lltl_V 
.1    ill    till' 

rs. 

flit    of    il 

iiinil  th:it 
•  ilisi'iisf, 
itliuloLi'y ; 
tliiit  any 
•iiiiilit'iDii. 
is  si'lili'iii 

llldloLliral 

iK'iiiix  iii> 
s  to  tri'iit- 

t    may  In- 

Of    tlllM', 

(•  is  iiy  far 
ct  only  ill 
syiiii>ti>iii. 

ly    a    >iil>- 

of  ciilil.  it 

well  as  t(» 

siliU'.  ami 
that   iiiuiiv 


,,,■  tl..s.  luitiuit.  a,v  w.amiu' l.v  »avi..  v.,T  houvy  llam.ils. 
1      ..  Juvavs  1 M   ill  till.  I.al.i.  i.f  .lin.ti.i,'  a l.u.n- 

1  ;;tl:.iK. siik-ami.w....ii..n  ..i... hi.  ."•-«- 

,li..   l.Mlv  well   l.ri.t..Ma,..lu  aiMi.  ami. sl..ss,U. 

,M.imli...  than  a  sin.l..  I.nivy  woolU.n  vest  wi.    .        ^ 
Wlmn   .111-  ,...-..   l-V'.-.  •! u..f  V..S    alisiulis  ,11. 

,vH-v.lial..ru.,.ati..,.tslioMl.ll...,.oviil...lw.,lial,..av 

-,.,,.,,,.„  .l.ouliM..  l..-oti..t...l  hum  .lam,...-  IN  u.  an. u 
'lUsl samltl.iu  -tt..,ii...ilks.H.ksu,..l.T> IK-n 

"'"\:  u..  l.av..  al.-.-a.ly  so..,,  tlu-s.  ,.a.i....^  ^.'v  HU-lv  to 
,,,;.:  iliv.  liai-sli.  sialy  ski.is,  s.,  that  ,V..i,...»t  w>..-m 
l:;;;;.i..,witl asmnalst..ami.rh..t-ai.-l.atl.s.sl.k..ly... 

pii.vr  hiirlily  I'.ii.  li.ial.  ..  •  ,   ..  ...u-  i^ 

'     N,x,   ,..     l...  .rmt.'tii-  tn.att.mt.t   ...   hi.mtm.al   .vslUs  ,h 

.,;.nWi..  .1 r--^    ami  ..f  alltWni.  ..   .-.-.•, 

;,".;  wl.iil.  ..-.•n.s  to  1 f  tl-  .....St  l-..t.t         '"'''-tu- 

i.ati.'iits  is  walkimr. 

^    N..niatti.rhosvu.aktlmya.vo,howmml.  '  ">  ""■ 

,.lai„  of  iK.l.ility  ...•  iUti,,Mm  o..  .'X.-.tio-i.  v".  ^^^^^'^^ ^^f'^^ 
M..1.- that  till,  sl.all  walk  .a.;l..h.y  .........  -tl..,^ 

,,U,.out   .xtro.m-   fati,..m.      If  .t    .s    t-'/''""'^     '  '  ,; 

t,,.,v  will  soon  iK.  ahl.  to  ...ak..  thro.  ...•  i...u-.     !-<   jL'  -' 

....   th.   .Hsta......    ....til   tlu.y   .a.,   walk    l.o.ii    >,x    .o 

Xli.  ...il.-- -y '1"V-     Thoy  .....St  .....  l.'.us.  .h....s.lv..s 

f.ir  a  littl,   ."liii  or  colil. 

, ,  .,„../.-K..r  ,1...  uv.„„.„.  "I-  .1-  i«ti".|-:".- ;: 

;         u,..  Ti;....  (i.a.  i.av,.  v-.v.-i  i"-';™;' '"  '"7 

;„„1  .vawnia,  l.n.nnJc  of  uis.'.nc  l.rc.«.ib>..l  ;u  tlt.uuw 


222 


DIMiETFS. 


solution,  or   arsenic   in   tin-    form  of  Fowler's  solution. 
Villi  riiin,  (|uiniiit'.  nitnite  of  silver,  and  mineral  watiT. 

Kenieilies  that  have  lu'eii  hiirhly  extolled  \\\  some  writers 
liiive  fiiiied  entirely  in  the  hands  of  others,  owiiiu'  no 
doul)t  to  tlie  faet  that  many  of  the  eases  have  heeii  .'ases 
(if  transient  <rlyeosnriu. 

Amonti-  the  medicines  thus  recommended  are  hromide 
of  |i(.tassi\im,  snudl  doses  of  calomel,  iihosj.horus,  stry«h- 
nine,  iodoform,  iodol,  sulfonal,  sulphnr.  salicylate  ot 
sotlium  or  salicylate  of  hismnth,  and  the  Hlkalies,  es- 
]>e<'ially  tiie  carhonate  of  lithia  and  many  others.  I'nder 
this  head  would  come, 'of  course,  treatment  hy  alkaline 
mineral  waten;.  In  Europe,  (\irlshail  and  Vichy  are  the 
most  favored.  In  (^difornia  we  have  many  excellent 
alkaline  waters,  our  Viciiy  heinu;  very  similar  to  that  of 
France. 

In  itrescribini^  eodeia  it  is  well  to  commence  with  a  halt- 
grain  three  or  four  times  a  day,  either  alone  or  in  eom- 
l)ination  with  valerian  and  (luinine.  A  favorite  prescrip- 
tion with  me  is — 

R   Codciio,  t:r.  »s  ; 
Ext.  vuloriiiiiii'. 
Quill,  siilpli.,  im  i:r.  ii.  — M. 
Big.— Threu  to  five  times  in  twciity-l'"ur  h'\u-. 

Some  of  these  patients  are  very  t(derant  of  opium,  and 
will  take  two-  to  three-jrrain  doses  three  or  four  times 
daily  with  the  etfeet  of  lesseninjr  the  sujrar,  polyuri  >,  and 
polydypsia. 

It  is  usual  to  prescribe  the  bromide  of  arseni"  as 
CU'mens'  solution,  commencin^tr  with  throe  drops  after 
each  meal  and  increasin<r  the  dose  to  six  or  ei^rlit  drops. 
This  remedy  in  my  hands  has  proved  second  only  to 
opium  and  its  alkaloids. 

t^ulphur,  alone  or  in  combination  with  iron,  answers 


'^!<  :^ 


"**^i. 


^  .,:jR?-^  ...,~k^M.Ji,,^'iih^y'>:,^'mi^.^:'^-^^^ 


es'^SBisar. 


/)/.i/iK77:v  yiKi.t.irrs 


•l-l-^ 


well  i..  .•as.s  that  .lo  n..t  sM  n..<lilv  to  ui.imu  or  .rs.ni.. 
'   .ntlH.;uu..ousnu.M.l.nnu>ot-tlu.alun.n.an-n..K,l    > 
II  skin,  tlu-  swout-lan.ls  1.1..,^  .U-fuu.nt  .n  aln.ost  all 

*'' For' mti.,.t.  wl.o  Uv.  in  malarial  .-limatos  or  ar.  tlu- 
„.L  .,  uf  .-hroni.  malaria,  tlu-  follow.n,.  vn.s.r,pt,on 
wili'  olt..n  ,n.ve  H.rvi.-.al.U.  in  loss.nin.,  the  i.ronunonl 
svnuitonis: 

li   Aiiili  iirx'iiiiisi,  !;r.  i ; 

Ext.  vftliTittini', 

(iiiin.  >ulpli..  Aft  51; 

Si,,_„no  pill  fr-n.  tl.ivc  t..  six  limos  .hiily,  with  an  occus,„nul  ni.r.unul 
laxativi'. 

Other  n.^licino.  will  ofWn  have  to  bo  a.lininistoro.l  vn 
thi.  .IKcas.  tor  .u.-h  conq.li.ations  as  may  .0  tou.ul  m  the 
tt;'uar<as.     This  .an  easily  Uo  a,>ti.u.al.l   rom  the 
•arioty  of  patholo-ieal  conditions  tonn.l  m  .l.abetes. 
""i.-Tl.o  ol,i:.-t  to  bo  attainoa  by  .hot  -  to  roauoo 
.lvka>mia  an.l  thus  roduoo  the   .ly<-osuruu      WIpIc  Ave 
flo     ot  know  h<,w  numy  of  the  ,atlK>lo,u.al  eon.htum 
tllul  post  uu>vtont  are  ,n>.luee.l  by  the  ----;i-;^  ^ 
of  su  ju-  \n  the  bloo.l,  cxporienoe  teaehes  us  that  it  nc 
lessen   the    nnantity    of  su.u^ar   the    pat-ent    munoamtel 
t:^us  to  re^un  hi/ strength.    We  aeeou>phsl.  tins  ol^oot, 
;,;;;    Iv     th';   reauetion   of  sugar,  by   eUmmatmg  from 
^     2    all  saocharine  matter,  as  well  as  such  tooas  as 
eontain  stareh.     The  auuexed  list  will  serve  as  a  guule 
to  the  proper  aiot  of  suoh  patients. 

The  ahlbetio  patient  may  eat :  almoml  rusks  almol 
bisouits.  gluten  bread,  gluten  biseuit,  Btale  breaa  (toaste.l), 
In- u-aA  bacon,  butter,  cheese,  eggs,  boet^ea  ana  tlnn 
soupsfbeU  mutton,  gante   una   poult.v :    hsh,  oysters; 


•2l'4 


DIMtKTES. 


ciililiMi:!',  Uttiicc,  striii.ir-l'fiiiis,  trrcfii  pl'a^^,  toiiiatcns, 
spiiiiicli,  <:i'.'»'iis.  olives,  artifliokcs.  iisjiarairus ;  <Mistanls 
without  siiLiiir.  jfllii's  >nis\vi'i'ti'iH'<l ;  lea,  coHct',  cocoa 
without  siinar,  water,  mineral  waters,  claii't,  milk.  hutttT- 
iiiilk;  aciij  tVuits.  lemons,  cherries,  currants,  strawherrii's, 

nuts. 

The  t'ollowin.ij  articles  must  he  iorltiihleii  :  |>eas.  heaiis, 
lentils,  potatoes,  sweet  potatoes,  carrots,  heets,  rice,  maize, 
wheat  liour,  oatmeal,  macaroni,  liver,  made  dishes,  arrow- 
root, luickwlu'at,  sairo,  tapioca,  puddiniis  and  pastry  u'en- 
orally:  apples,  bananas,  and  sweet  fruits  u-eiierally,  iii- 
(.'liKlinLT  raisins;   sujxar,  ehoctdate,  aU's,  swi'et  wines. 

My  own  expi'rieiice  is  that  jiatients  do  hetter  on  the 
nii.xed  diet  indicated  hy  the  above  list  tlian  on  a  too 
exclusive  diet  as  has  bei'U  ot'tc^n  recommended.  Stuiie 
writers,  for  instance,  recommeml  the  restrictitui  of  the 
))atient  to  a  meat  (Hot  exclusively.  l>r.  Donkin  a  few 
vears  a<ro  advised  a  diet  eonsistin.t:;  only  of  skimmed 
milk.  i'>oth  of  these  T  have  tried  upon  more  than  one 
occasion,  with  sitjfnal  failure. 

The  diet  of  diabetics  must  be  strictly  sujiervised,  as 
many  of  them  liave  ravenous  appetites,  are  always  thirsty, 
and  eat  and  drink  to  excess. 


ClIArTER    TIL 

DIABETES    INSIPimS    (iMJIATHIA — ISOZEMA — HYOSIRIA). 

r)lAnETES  INSIPH>1'S  is  a  e()nditi<»n  eliaraeterized  by  a 
persistent  increase  in  tlie  (piaiitity  of  urine,  vliich  con- 
tains neither  albumen  nor  sugar,  and  usually  aceoni])unied 
by  polydypsia. 


/)/.! IIF.THS  ISSIl'ini  \. 


225 


,  toinatoc'S, 
is;  ciistiinls 
ofi't'i',  ('(icoa 
iiilk.  ItiittiT- 
^ti'awln'nics, 

|lCilS,    lu'lltlS, 

,  rirc,  iiiaizc, 

isln'S,  lllTOW- 

I  jiiislrv  LTi'ii- 
I'lifi'ally,  iu- 
wiiu's. 

I'ttor  oil  tlie 
111  on  a  too 
ili'd.  Soiiio 
ctioii  ot"  tlic 
oiikiii  a  IV'W 
of  skiuiuu'd 
)vv  tliaii  one 

i|i(,'rvis('(l,  a8 
ways  thirsty, 


-IIYOSrUIA). 

'tori/.otl  l)y  a 
I,  wliivli  <^on- 
aceonipanied 


In  (lalen's  tinic  tlic  tiTiii  dialu'ti's  iiiclniU'd  all  cases  of 
jtolvuriu.  It  was  not  nntil  clu'iiiical  analysis  of  the  uriiu' 
•  li'iiionstratod  siiu-ar  in  sonu'  cases  that  the  ditfcrcntial 
diairnosis  was  t'stalilishcd. 

lvrii)i,iMiY. — \Vi'  arc  absolutely  ignorant  of  the  etiolo<;y 
of  this  (■onditioii,  and,  as  is  the  ease  with  all  diseases 
wliose  causes  are  unknown,  many  tlieories  as  to  its  oriirin 
have  been  evolvech 

Thouirh  in  many  cases  tlie  kidiu-ys  havt-  heen  found 
diseast'd,  it  is  very  iircthalde  that  this  disease  is  not  of 
renal  oritrin-  ^'*'t  it  is  possible  that  in  some  cases,  at 
least,  it  has  its  oriirin  in  a  nutritive  derani^ement  or 
(U'<i'eneratioii  of  the  tuft-wall  or  its  ct'llular  lining;.  Tiie 
Maljiiuhian  vessels  themselves  may  sutier  det^eiieration. 
The  dcireiieration  and  perhaps  des(|uamation  of  the  mi- 
eh'ated  lininu;  may  not  only  allow  the  more  rapid  Hltra- 
tion  of  urine,  hut  also  weaken  the  tuft-wall  and  allow 
the  dilatation  of  the  vessels  of  the  tiitt,  or  the  vessels 
may  dilate  in  coiise(|Uence  of  degenerati<»ii  of  their  walls. 
It  seems  to  tue  possiliVe  to  have  dilatation  of  the  tuft- 
vessels  independently  of  vaso-motor  paralysis.  .'!ie  de- 
"•enerative  chamres  could  well  he  owiiii:;  to  chemical 
ehantres  in  the  hlood.  Inosite,  for  instance,  has  heen 
found  in  the  urine  in  some  eases  of  this  disease,  and  it  is 
l(ossil)le  that  an  abnormal  material  may  yet  he  found  in 
the  urine  which  shall  be  as  pathoirnomonic  of  diabetes 
insipidus  as  snijar  is  of  diabetes  mellitiis. 

The  consensus  of  opinion,  however,  appears  to  be  that 
this  disease  is  a  neurosis  and  has  its  orij;in  in  the  dilata- 
tion of  tin'  renal  arteries  from  paralysis  or  irritation  of 
their  vaso-motor  nerves.  It  seems  to  me  that  for  |»olyuria 
to  be  produced  it  is  not  absolutely  necessary  that  there  he 
either  dilatation  of  the  renal  arteries  or  extra  blood-press- 
ure.    It  is  very  probable  that  there  are  special  secretory 


^.  ( 


h. 


m 


-.3!W!ru£KS?^^';K?:^tew-'^iti^-  -.■;?:"r?rai'r--«pn>«w  * 


-BL'W-'^'Wr'JU JM.'J.'  . 


2'2(\ 


DiMir.rrs: 


;;,;.,,,,„..„  ,.x..lu>iv,.lv,o,l,..,ul...U.s.  Tl...l.lK.n..H...s,n 
,1,.  ..nil.n.  of  tlH.  tulM.K.s  i.MlH'ir  .unvulul.W  :.M.I  turn.uus 

.,„„-.....,.  unlvlK.  lor  tlu.  ,,un.o».or,vt;mhn,tl:.  too 
,,,,„,  .....p..  ..l"  .!-.•  tilt.ml  urin...  N..W.  iH  us  >n,,,..- 
,li,,lH..,Lial>....v,in,n..n...iil.vs:.v,.ralv^ 

lH.,H...   .1...   .nl IUts  linl..  or  nu  vual   —':'-• 

....a,,.,  of  urin.,  tl...  rosult  will  br  ,-lv>.na  u  uliout  .11..- 
t.,ionof,lH.l.l..o.l-v.ssJsor.xtral.lood-,.vssn.v.      Uns 

.,,...... as  n.tional  an   .x,lanaru.n  on.varn.K.    . 

,1    ,  whi.l.   a.tril.ut.s  i,  ,o  ailat.tn.n  ot   llu.   .vnal     ...     - 

V..SS..1S.  lntluMat,..r..as.  tlu-n.s,s,.n....o,  tWljUU 
V.SS..1S  wonl.l  s.ill  Imv.  t..  !..•  ov.Mv.mH..  an.l  .•.■rta ml      iK 

,,,..,.,,.,.n.ssn.v  tV..n.  nuMv  dilatntiou  ..r  tin-  v.ss.ls  ot  th. 
tult  vou\i\  not  In-  viT.v  ,-i-m.tly  in.iv:.s...l 

,,,,  .  ,.^^,   „,,t   in.jnri.s  t..  tlu-  ..■rvnul   synq^.tlKt,..  ... 
s,inal....nl..rhM.ita,i..n..niu.ll....rortlu.touHl.v..n.-U. 

..n.v...Mtu.n.nn..i.-..n,in<..Ml.isl.nn...,...y^^^^^^^ 
I^.ili..-anl...l.n..nstn.to..ltlwUtlK.   rc.nal     nn.to      . 

,.,,^i.lv.l    ..vor    l.v   si..'.ial    s...Mvt..ry    nvrvc-fl-n..  .t   u  .U 

of  .lialH'tc's  insipidus. 

.SV,-._Tluso,u.liti..ns...n>st.>lu"nuu-.  nuMv  ...ju  nt 
in  nu.n  tlun,  in  w..nu.n.  tlK.  ,n.,.ovt,..n  l...n,.  l...n  tla 
,anu.  as  that  in  .lial...t..s  nu.Uitus.-al...ut  tluv..  t..  ..m. 

;Lno    a..>    is    .x.n,,t     tn.n.     .lial...t.s    n.s.pj.l,;.. 

TiL  all  ttu:..as..su,  t..  sixty  y.a... .fa,...  t^K-t. u.ty 

n./;n.n.   tw..n,yt..  tit-ty,.n..ln.val...ut   tw...lnnls.,l 

;;,;.  ..as..s,  tlu.  t..u  y..ars  tV..n.  tuvnty  t<.  tlnvty  Wu.^  tlu- 
.U-ra.K'  in  wl.i.'h  Hi..st  .-ases  ...■.■ur. 

//...%.-lKM...lity  is  .vi.U-ntly  u..t  a  v.ry  a.tnv  .tu- 


re  (list I'll '- 

iTllliTS  III 

I  torliu'iif* 
o-  till'   too 
s  siipposc 
Ivzfil   ;iinl 
lice   to   tlic 
lioilt    dilii- 
ll-r.      Tills 
vdruriii  as 
Mill    l>loo(l- 
thc   lilood- 
rtiiinlv  tin' 
ssi'ls  of  the 

|iiitliftic  or 
ill  vfiitr'nU' 

II  is  .-troiiir 
)t'  jiolyiiria. 
fiuH'tion  is 
iiH's.  it  will 
vous  oriiriii 

»n>  tVcfim'nt 

_r  lioUt  tlio 
(■   to  olH". 

^  iiisiiiidus. 
c.  tlu'  tliii'ty 
vo-thirds  oi" 
tv  bc'inji"  tlir 

■  iirtivc  ctio- 

systciii,  siifh 


/)/.i/iK77>  i.\sirii>rs  -s^i 

as  falls,  jars.  coiuMissions.  or  Idows  on  lli>'  head,  or  oii  the 
si.iiir,  iiiidoiil.ti'dly  play  an  a.'tive  |.arl.  'I'luiioi-..  apo- 
pK'NV.  and  lu'iiiorrlia,L^is  and  intlaniiiiations  of  llu'  Inaiii 
i„v  anion--  \\n-  .'aiisfs  ;  so  al.>o  mv  r\c>'s>i\c  nnnlal  niio- 

tioiis. 

Till'  alnisi'  of  alcohol,  of  iliurrtics.  or  of  icc-Wiitrr  has 
sonictinirs  Ikmmi  followrd  hy  this  .•onditioii  :  and  ...•.a- 
sioiiiilly  it  o.'ciirs  as  onr  of  the  s(M,iuda'  <.f  the  acute 
ilUeetioiis  diseases. 

|'.\Tiloi,(i(;v.— Diahetes  iii>i|iidtis,  liko  diahetes  niellitiis, 
has  no  liNi'd  i.atliol,.iry.  Thoiiirh  as  yet  theiv  ha-  hirn 
no  one  ofu-an  invarial.ly  found  diseased,  lliei*'  are  tew 
east's  in  which  some  one  or  more  origans  art'  not  found  in 
a  iiatlndoLrical  condition. 

To  he  sun',  tin,'  kidiu'ys  have  heen  ofteiier  found  (lis- 
eased  than  in  diahetes  iiiellitiis,  sometinu's  in  a  c(.iiditi(»n 
of  de..:-cneratioii  ;  a-xain,  a  .iTivat  iiumher  of  ahscesses  Inive 
heeii  found.  .\t  other  times  a  hyperaMiiia  or  dilatation 
<,f  the  hlood-vessels  will  he  jiresent ;  while  in  some  caseH 
the  kidneys  have  heeii  in  an  a|>i.arently  normal  state.  In 
many  instanc»'s  the  hrain  has  heeii  found  in  ahout  the 
same  diseased  condition  as  in  diahetes  nu'llitus;  that  is, 
tumors,  tuhercular  masses,  and  deireiurative  chan.i^es  ia 
the  Idood-vessels  in  the  floor  of  the  fourth  ventricle  or  in 
the  mi'diiUa  ol>lon<>-ata  have  heen  ohservi'd. 

Symptoms.— The  constant  hyiH'rseereti(.n  of  urin.'  is  tlu- 
ehara.ti'ristii;  symi.tom  of  diahetes  insiifnlus.  Most  of 
the  other  symjitoms,  as  thirst,  emaciation,  ami  dryness 
of  the  skin]  are  j.rohahly  dm-  to  the  enormous  amount 
,,f  wati'r  vohle.l.  Patients  not  infre<iuently  |.ass  from 
two  to  four  irallons  daily.  As  a  rule,  these  i.atients  make 
a  greater  <iuantity  of  water  than  do  those  with  diahetes 
mellitus.  The  urine  is  li.icht  in  color  ami  wei.u'lit,  the 
^leeilie  gravity  varying  from  100:5  to  1010.      it  is  usually 


saswi^tsiw'ra"'*'^^^*'****'^''*'**''^ 


l»Ta3aSSi»KPK^WS«««!«!Sa8PS«W-™™"'''-^^ 


.Jj 


•2-2f< 


DIMIKTI-.S. 


v,.iv  sli-htlv  a.i.l  iin.l  (lr..oi„,M.s.s  qui.kl.v.  1 1n-  H..h.ls 
„.a"v  1...  inriva^..!.  .s,...riallv  una  au.l  tin-  i.lu.si.l.atrs. 
lH/,.itr  is  o-va^iomillv  .Irtivt*..!,  as  is  alx.  hip,.«n'i.'  ari.l 

T1...S..  uati.'Mt>  aiv  imt  >o  likely  tu  MitUT  tVo.u  .arl.muK.s 
a,„l  l...ils  as  the  sul.jeets  ..f  diaLetes  MU.Uitns:  er/e.na 
,„„1  ,,,„nlus  are  iH.t  so  apt  to  appvar,  imr  .>  the  api-et.te 
so  often  inemised,  as  ill  that  disease. 

Manv  more  svmpton.s  of  this  .lisease  an.  enuM.enile.l 
hv  wri'ters,  l.ut"thev  are  onlv  expressive  ..f  the  (hllerent 
;„,,„,.„.,i.,,l  .,,n.litions  that  we  have  alrea.lv  seen  t..  exist. 
(),u.  pi.tient.  in  a.hlitiou  to  hv.lruria  an.l  thirst,  may 
Inve  a  tumor  of  the  l.rain:  another,  .h-eneratn.n  ot  the 
medulla,  or  tuheivulosis,  or  syphilis.  The  symptoms 
varv  aeeordin-lv:  for  mstanee,  in  one  there  will  l.e  a 
.Usn.rhanee  of  "sensihility.  in  another  a  disturhanee  ot 
,aoti..n,  whileathinl  may  sutler  from  headaehe  or  eon- 
vulsions.  While  the  thirst  is  often  .piite  as  -reat  as  in 
(liahetes  mellitus,  the  houlimia  is  rarely  present. 

j),,„^„sis.— The    term    diaheles    insipidus    is    used    tor 
n^^t    as  we    use    the   term    neural-Ma    tor  pa'.n. 


iiolvuria 


When  pain  is  the  result  of  or-anic-  lesion,  sueh  as  eaneer 
or  intl.immation,   tumors  or    uleers,  we   are   not   ,n   the 
,,,l,i,  of  desi-uatin-  it  as  neural-ia.     ^\  Ium.  <.ne  is  su 
i;.,i„...  ,,ain  for  whieh  we   eaniiot   liixl   a   eause,  we   si 


ut- 
'V 


the  patient  has  an  attaek  of  neural-ia.  W  hen  a  patient 
ha.  hvdruria.  i>assin-,  say,  over  a  hundred  ounees  ot 
urine  per  .liem,  an<l  we  find  no  ..r-aiii.'  lesion  to  aeeount 


i;,,  it,  we  .lesiixnate  the  ease  as  one  of  .Uahctes  insipn  us 
Iwa<  ealled  in  eonsultati<.n  not  Ion-  sim-e  to  see  what 
was  sippose.l  to  he  a  ease  of  .liahetes  insipidus.  I  he 
.„ti,,„t  was  a  y<.u.>u^  man  of  twenty-tive,  who  pa^^^d  one 
,„„„lred  and  tiftv  ..unees  of  urine  daily.  1  tound  a  typieal 
.ase  of  amyloid  .le-eneration.  This,  then,  was  not  a  ease 
of  diahetos  insipidus. 


i 


DiMir.Ti'S  lysii'inrs. 


229 


'he  solids 
lospliatis. 
■\v  iifi'l. 
iirliiuiiK'^ 

;  ;    I'czcllia 

I'  mn'i'titf 

uiimiiilid 
•  ditViTrnt 
n  to  exist, 
lirst,  may 
ioii  of  tlu- 

^VIlHltoIllS 

will  1k'  a 
irhance'  of 
111'  or  t'oii- 
irrt.'at  as  in 
t. 

s  iisttl  for 
I  lor  jKiin. 
\\  as  cam'*.'!' 
not   ill   llie 

oni'  is  suf- 
isi.',  \vt'  say 
.'11  a  i>atioiit 

OlUU'C'S     of 

1  to  accoiuit 
s  insipidus, 
to  si'i-  what 
[,i(his.  The 
I  passed  one 
ind  a  typii-al 
IS  not  a  ease 


A  few  months  airo  1  was  eonsiilti'd  l.y  a  nudieal  praeti- 
ti.m.r.  aire.l  sixty-tive,  for  dialutrs  insipidus,  lie  made 
ahout  oiu'  humlred  oiinees  of  urine  .laily.  lie  presented, 
with  the  exeeption  of  alhumeii  and  easts,  a  well-delmed 
ease..f  intertul.ular  nephritis,— irouty  diathesis,  ath.'roma 
of  valves  and  arteries,  and  hypertrophy  of  th*'  leit  heart, 
—and  had  had  an  attiiek  of  Inematuria  two  years  h.'tore. 
He  eonsi.lere.l  his  ease  oue  of  .liahetes  insipidus  heeause 
he  had  found  no  alhumen  nor  easts. 

l»K.mN..sis.— .\s  we  know  nothin.tr  of  the  etioloi;y,  and 
us  the  patholotrieul  .'oiidition  found  after  <leath  varies  fn.m 
ahseesses  of  tlie  khluey  to  tumors  of  the  hrain,  the  pro.t;- 
nosis  must  of  euurs,'  vary  aee<.rdin.ir  to  the  individual  ease. 
A.'e  is  not  so  important  a  faetor  as  it  is  in  diahetes  niellitus. 
Some  eases  run  a  rapid  course,  lastiuf?  hut  a  few  months, 
in  spite  of  all  treatment,  while  others  are  very  ehronie, 
the  patient  liviuiT  f.»r  years  in  comparatively  .trood  health 
and  without  treatment.     It  is  a  very  curious  fa.'t,  otteii 
settiiiir  at   delianee   the   most    skilful    pro.irnosis,  that   in 
some  of  the  most  acute  cases,  where  the  emaciation  and 
del.ilitv  have  heen  extreme  and   the  polyuria  ixcessive, 
no  iKitlKdou'ical  i'ondition   can  he   f.uind   after  death   to 
a.-eouut   for  the  svmptoms.     As  a  rnh',  eases  following 
iu.jurv,  as  well   as   thosi-    that    eommence   suddenly,  are 
likely  to  he  acute,  while  many  of  the  ehronie  eases  die  ot 

intercurrent  disease.  •     •   •  i 

TiUv\TMKNT.— We  have  no  specific  for  diahetes  insipidus, 

and  it  is  necessary  to  rememher  that  it  is  the  patient  and 

not  the  disease  that  is  to  he  treated. 

We  mav  follow  the  same  ,i:eneral  plan  of  treatment  as 

in  diahetes  mellitus,— that  is,  hygienic,  dietetic,  and  me- 

dicinal.     The  dietetic  treatment  in  this  disease  is  much 

less  successful  in  alleviating  the  characteristic  symptoms 

than  it  is  in  diahetes  mellitus. 

'JO 


I    I 


II 


■  :.-^'^;y.  .«lW-*1E.!aKfM«'R!S»3-l 


B,a3j^/fj»««^sx=£;;*.«Ba:o^8*«----'ira»'^^ 


tm 


'IW 


/»/.  I/!/; /•/>■. 


,,,•„„..,•,;,.,,,, .,n..tii..irlli.-tlui.lHan.lfu...l  has  nut 
jrivM  .■Mrnura-iu^  nM.lt>,  s..rvi.,;r  only  to  m.-ivas.  tli. 
fiiiafiiitinii  aiiil  iltliilitv. 

,.liM.a^...,ttln~natiuva.v„.Mv>sanlvas  inn.n^tant   a.ul 
,lisa,M-i..tiM^  a>  tlu.  ,...l.olM;rv  ot' tlM.  .lisras..  i.  UT.-u^^^ 
N..vl'tl..l->  w..  fuM  .■.TtaiM  Mu-ai.in.s  .xtulUa  Wv  wntors 

(»t'  r<'|inlali<>n. 

-,,,;^,,  ^^  ,,..,li,.,,,.  ,,av  1...  tnn.i.l  t..  .vlirv..  a  synipt.....  M. 

a  .vrtaii.  nu.nlK.r  ..!■  ,as..s  of  tln>  .li>.as..  \s  to  lu.  .n,..H.m1  : 

,„„  „,,   „.vu,.„   ,„.,.li..i,u.  .l.ouhl  1..  >;-.uMu.n.M  as  u 

,„,,.  ,;,,  .iial..t..s  u,>i,.i.lus  S...-M.S  tl..  h.-,.^l.t  ot  al.sunhtv. 

VaUria...  .an.i.liur.  ..i-iun..  or  .U.-tncUv  u.a.v  .vhrvc 

,1,,  .vMiplo,,,-  iiMu.uro,iM-«i''"t'*'^^-l''l^"  »»''•  i'':^!''''''''''' 
.,,■  •,,;„,.  .t,v..hnin..  or  .(..iiiiiu-  ..ft...  l..-..vc>  ns.l.i  ...  .'asos 
,,,•  ,„„,H,ia"a...l  a.l.ir.tv.  Ast.-u.,!.o'...s.  s...-l.  ..s  M  and 
„„„•....  so„>.ti....s  U-ss....  tl.r  .,..u..tity  of  .,.•,...••  NU'.vH.y 
.n.l  io.li.l..  of  potass-,,....  sl.o„M  !..■  a.l,M,...sU..va  w  .;'.. 
„,.,  „i.,,.,  i„s  or  is  s„s,K..t.a  of  havm.t.-  syplnhs.  D...- 
n.fu's  l>av..  l.a.l  th.i.'  a.lvo.atcs.  I..,t,  of  .-...•sy.  oo.ikl  bo 
l,e„.f..ial  o,>lv  •„,  cortai.,  oases  with  kidney  lesions. 


(MI  A  I'TKK    TV. 

AXAZUTIUIA— ul.l.il  KIA— A/nrrKIA. 

An-      .^UI^  is  a  e..n.r,tion  <ha,aete,-i/.ea  l.y  the  see.v- 
,i.„;o.  a  .,onnal  a,n..unt  of  n.-ine  whi.l."  is  dehe,e.,t  ... 
„;.;.;,    -n..  s,eeiii<-  ..-avity  .......es  f.-..n.  1002  to  DOS,  and 

neithe.'alln.iiien  „o,- easts  a.-e  pivsent  _ 

Si,-  \„.hew  Chn-k  ti,-st  dese.'ihe.l  these  eases  in  IMS.}, 
as  renal  inade^uaey.  and.  having  had  an  opportunity  to 


m^M 


\y.i/.nrrHl.\—<>l.l(irill.l—.\/.nTllll.\ 


231 


,„nko  i>  iM.st-iu..rtrii,,  \\>nuA  im.  AUvam-  of  tl.c  \iuhu-y. 
Tl.c  Ui.lm-vs  rttriii  iiir;ii»al.l.'  o\'  fxrivtin-r  ii  -niit.r  .|iian- 
tilv,  iiniwi"llistiiii(lin-r  tti>'  I'iif'u'iit  iiiiiv  iKirti.Ur  of  a  laiy..' 
.„;„„„„  „,•  ,i„i,i.  Thr  -.'Mrral  cl.ara.'t.T  of  ll.r  .lisni>^i', 
is  v»TV  similar  tu  that  of  ,lialK-trs  mrliilus.  Tl.r  |Mtici.trt 
iM.mi.iaiii  ..I'wcakiirss,  i'ina.'iati..u,  liradadu'.  uaii.M'a.  and 
.■hilly  s.nsatiuns.  'rii.'V  Lrar  suriri.al  oprrations  l.a.lly, 
and  ot't.'ii  dif  of  inlfrciirri'Ut  disi'as.-. 

'PivatuK'Ut  soeins  to  fail  to  ivstoiv  tiir  linutioii  of  the 
kidiifys, 

OLUintlA    AND    AZOTUIUA. 
It  is  a  fact  that  many  \n-o\Av  maki'  nincli  h'ss^  than  the 
avrni'--.'   fortv  to  sixtv  oun.-cs  of  urine   \h'V   dn'in.  with 
in.MVii"sc  ..f  sluH-ifn-  .irravity  and  of  tlu-  ann.unt  ..f  niva  i-.T 
ouii.T.  and  vet  are  fre.'  from  disease  of  tlir  kidn*ys.      A 
f,i,nd  of  mine,  a  m.Mli.-al  man  of  ahility,  iid'orms  me  that 
jil.ont  ten  vears  airo  lii^  attenti(m  was  eaUed  t<.  the  small 
nuaiititv  .d-  urine  that  he  was  passin-.     Ur  made  an  ex- 
amination  of  tlie   urine,  and    also   had   it  examnie.l   by 
several    medi.'al    frii^nds.     He  states  tluit.  re-anlless  o\ 
the  qnantitv  of  ^*olid  or  li-iuid  nourishineiit  lie  has  taken, 
or  „f  nu'dieatioii,  hi'  has  not  dnrin-  th»'  past  ten  years 
nnide  thirty  onnees  of  urine  in  any  twenty-h.ur  eonseeu- 
tive  hours. 


)J  * 


j--,4<«»«wu.<iws»»a*«5»'<«»»»=»^'**«'««'*^  ••***'*'"*"■ 


r.M»wJ<».H«t'f««t*«»«  -UMiit*mmKstiimf»iisxi  - 


tm 


1  N  DKX. 


At-(«s.<  of  kiiliii'V,  107. 
Ac  >iiiiiii'iiiiii,  -I**- 

Aci'l,  liipimiir,  4'.». 

ciXlllK',  4'.' 

(iXHluric,  4!>. 
uric,  4H,  W,  r.7. 
Aiiiti'  <y-tit'H,  188. 

lii'I'hrilis,  T'l. 
Ailiuiiit'ii,  "It!. 

sijjnitti'uiice  of,  07. 
ttsts  for,  0',),  70. 
thi'iiriis  of,  <18. 
A'livldiil   Ji-neiieriitiiiii  of    kiilnoy, 

l-JO 
Aiiii'i  liii  of  kidney,  4'i. 
utioloKV  of,  45. 
jiatholoi^y  of,  45. 
pro)ino8i!*  of,  4(1. 
»yiiipt'iins  of.  4-5. 
trt'iitiiiint  of,  li), 

AllilSlhcsill  nf   MikMcI'.    17H. 

ihioiul  liydrati'  for,  179. 
etiolotty  of,  17H. 
cymiitoiiis  of,  170. 
tfi'iitnu'iit  of,  170,  180. 
Anatomy  of  bladder,  1(18,  171. 
of  kidney,  7. 

Bowman's  cnpside,  10. 
cortienl  portinn,  '.' 
Midpiijhmn  tiil't,  10. 
inedulliiry  portion,  ft. 
pynmud",  10. 


ao» 


Aniil.'iiiy    of    kidn>'y,    uriniferoux 

tuliuies  10. 
Anu/oturiii,  -HO. 

<ltliiition  of,  'JllO. 
Aneliri^in  III'  p'llid  M -I  Iv  47. 
Arterie!*  of  kiilney,  IM. 

iiiH'urif'iiis  of,  17 

dei;i'iii'riili"n  of,  4"'>. 

di-ince  of,  4ti. 

uinlioli^ni  of,  47. 

throiiilioKis  of,  47. 
Aspiriition  of  kidney,  15.'i. 

iiii'tie'd  nf,  \r,:y.  l.Vl. 
Aton.v  of  liimldiT,  17H. 
Atropliy  of  kidney,  'JH,  I'J:!. 

ptiology  of,  l-'i. 

piitlioli'ny  of,  I'.M. 

pro^no^is  of,  llil. 

^ymptoInH  of,  1U4. 
of  unters,  l.')4. 
Azoturiu,  1!30,  2M. 


Hertini's  columns,  1!1. 
Bladder,  anii'»tlie>ii»  of,  178. 

imatoiny  of,  1"',H. 

arteries  of,  171. 

atony  of,  178. 

beninn  Rrowtli^  in.  '-'04 

bit-i  of  eloth  in,  '20o. 

(•oaf  of.  170. 

de-rription  ..f,  100.  17(i. 

fort'it;n  bodies  in.  '2(».'i,  'JO.j. 

treatment  of,  -JO."),  206. 

i!33 


«rTWM1l««^"-' 


tnartR-x  J"-'~J-»  ->  •*  •kHf.^--'^''-'^  ■"  "' 


Ai 


2:51 


i.\i>i:.\ 


|»lii.l.|.r,u»l»-»i"n'"l"  •-'"■'  ; 

jjriiMl  ill.  '-'»>■> 

lllMllnnllliU''   "'•    '^^' 

|i\|iiiii»ilii'piii  III'.  I"'*' 
Ji>|M  iiiii|'l'.*    ••'  ''•'■' 
iiiliiiMiiiii''.i"ii  "•'.  l****' 
irriMlil''.  I'^' 
linuiiii  lilt  III'.  171,  1 1"' 
timlluimiil  LTiiwilis  III'.  ailU 
niui'iiiiii  i''i"i  'i''  '""• 
ihiiM'iiliir  iimt  III'.  I'l'"- 
iii.fvi«  iif,  1  Tl . 
i.i'uniluiu  III'.  n'J. 
ni'W  Kriiwtli*  in,  «"•' 

uiiil  fiiniu"  liii'Ji''^  '"t 
•Jd.l 
jiunilyi'ii'  "I'.  '**•' 
ixmitiiin  III'.  I'W- 
»hii|i<'  ot'i  I'i^' 

III  infiiinv,  10H. 
^/.^••(,  It'iH. 
njMiHiii  111',  '**!• 

►t in.  IHH, 'jn.-i. 

tiiliirnilii-iit  III',  '-^*'''- 
vurii'ty  iif  uMwlliti  in, 
vt'inn  I  if,  1"1' 
HIhkI  in  iirinf.  <M- 
HoWtimiiV  niliMili'.  10. 
Hrii^lit  .*  (li-iii-f,  '•i- 


'203. 


(,'iiliiili  III'  ' 
Ciiiiulus 


;yiil  ]iliii«|>liiiU'^,  137- 
,  i:!:?. 


y  iif.  133. 
ilucnci'  III'  »i:<'  "I'll  li'^' 
i.f  c'linmti'  iin.  135. 
Mii'kcl'.*  thi-iry  nl',  134. 
Cimii-r  nt'  Uiilniy,  l'J5. 
Cast'   n|>li.unini'i'  nf,  (i'l. 
(Irtliiiti'iii  "I',  •'il- 
fiirniatiun  i>li  ^^ 


Cii.tK,  liUliiry  I'f,  *H. 

viiri''ii'-  'il'i  ••''•  "•' 
ruliinlml  iniihn'i'.  ""■ 
Ciiiln  liri/.iiii:  nil  l<i-i  l*l'>- 
CliLiriilin  ill  Hiint',  64. 
('iirmiii'  ry"tiii».  '**** 
Ciriliiiiii'  kiilin'y.  '.'•• 
«..lmiiii-iir  Hirtliii,  13. 
t'niM  nil  It'll  l^lllnl■y,  '.'4. 
Criu.otii  in  ••limnii' lytili-,  •'•"• 
Criiiiiviii-  iii|ilifiii-,  '•'•• 

Cy-iiilu'i'i  1'^'- 

il.'tliiiiiiin  III'.  I'^'-' 

fliiil"«y  III".  ''■- 

lljnsrMilllll-  I'T.  1T4 

'  |iiilliiiliiiiy  nil  ''•'■ 

iiiliil  mipiiiiMtiiii'i'  l''"'i  '"••• 
Hyiiiiiliiiiii*  III',  IT3. 
tri'iiiniiiii  III',  l'i^4. 
(•yiit,.   il.nininilii'ii  »(  tl>"  k'J'"')'. 
'I'Jii,  131. 

Cynlili-.  I***- 
lU'Ulf,  IHH. 

(hliinil  hyilniti'  in,  196. 

clnlhinu'  i"'  l''^' 
UillniliiiM  III',  IHH. 
.lii't  111.  I'.M 
etinliiuy  III',  IHH. 
ijouty  tliHtlii'i'i*  in-  ^^^ 
liyivi.liTiiiic  injfcti'i"'*  tori 

ItM'i. 

injnrii'"  in,  1H9. 

jmtliiili'Cy  III",  l'''^)- 

j.i'(liitivt'«  in,  l'.»5. 

Rcx  in,  IHH. 

sviniitnnii  111',  li'l- 

tnutnnnt  nf.  1''3,  106. 
chrnnii'.  IHH. 

linniti'  iif  i>ii*li"n>  fi'i'i  ^^''• 
Ciilifiii-ni"    ininiTiil    wiiti'i-* 

fur,  I'.tH. 
etiiiliigy  of,  190. 


ISDF.X. 


i:\r> 


.,  MMl. 


III'  kiJiK'y, 

in,  \'M). 
I. 


<». 

in. 

ISO 

jf<'t 

nns 

lor, 

). 

!)0. 

15. 

V.tl. 

105 

mi 

lor, 

197. 

lunil    « 

iitfi 

)0. 


('y-tit,»,    rliiMiiic,    iiiinili'   "I'   -ilviT 

iMf,   l'.»7. 

|iiilli"l"U\  if,  I'.iO. 
.iiImI  III,  lt(T, 

K\  (llllllllll-    111',    I'.liJ. 

trriiUiHiit  'if.  Hilt. 
WH'ln'»  lor,  1U7. 
»u)iu<'Uli',  !>•>•■ 

ii(iii|.iU_\  111,  Ihrt. 
|iriii»iiiimK  lit',  111!!. 

J>\  lll|ltl>lllK  111',    U'-'. 

In iiiiinjit of,  lua. 

(.'v-tii-liiliiii-i-,  !>*''. 
fNil"plfi;i».  l"". 

(•IUlM'«  111",  lH!t. 

<!•  tIniliiiM  «(.  1«:i 

ill  liiiiiiinli'ilil'.  \M. 

in  iilil  wonii'ii.  I^H. 

iiMii|iiiiinH  iif.  1h;). 

tPiiUiii'iit  III',  IHl. 
('yt"riliiii;iii.  :tt!,  1H7. 

itiiiliii.'y  111",  18", 

ni'W  yriiwtli"  u»  niii'M'.  IH7. 

nyiii|)tiiiii'  lit',  1h7. 

triiitini'iit  1)1",  IH7. 

uU'iTiitii'n  in.  1*^7. 
('y-t"-pii'*iiiii-.  l^'- 

ilitliiiliiiii  111',  IHl. 

.•tii.liiL'V  111',  IHI. 

>\  lii|itiiiii''  iif.  IHl. 

tinctiHi'  "t'  liyii-c.Miiiius  t'nr,  182. 

tlfiillnrut  nl',  1H"J. 
("v-t"-|iii>ti<'il'<,   IHI. 

Cy>t-.  hvilutiils,  11)0. 
nf  kidii.-y,  120. 

cnniri'nitiil,  I'JO. 

I'linlllU'V  111'.   I-'O 

lii|mfiitiiiiiy  t'nr,  130. 
luitlioliiuy  i>f,  120. 
priiiliiiisiii  of,  13'J. 
Kyiniitniii"  of,  I.'IO. 
ticutiiifiit  of,  1.'!!!. 


l)iH.ii  niti"ii',  I'-il*. 
uii.yloi.l.  I'Jti. 
cy-tli,  I'JO 
iliiinnii-i»  of.  I'-'l, 
Hiiilouy  of.  Ii.'<». 
I'iat\,  l*-'"J. 

Iiirilii iiiK,  I'JO. 

,inil...|oi:y  of,  I'JO 
iiroijiiiKiii  of  I'JI. 
»yiii|it"in»  of,  I'JI. 

tl-i'lllllll'llt  of,    I'J'J. 

wiix.v,  I'JO. 
Di-iliimimiiM'  iii'i'liiiti',  71. 

Diiii.ii.-v  ::n>. 

hiMon  of.  'JiO. 

li\|iirtroI>li.v  of  lilidili  !■  ill.  'J0-, 

IIIKIIlillll'-,   '-'Jt. 

.l.-ili.itioii  of,  :"J4. 
aiiiuno.iH  i.f.  'J'JH,  'JliO. 
Hioloity  III".  'J"-">. 
cxcitinu  iiiu-i'«  of,  JJil. 
|iiiiUil>  ill,  "JJii. 
putliolony  of,  'J'J7. 
((yiii|>toiiin  of,  •J'J7,  'J'JH. 

t'lVHiiMi  lit  of,  -j-jo,  'j;;o, 

IllfllittIS,  I'll. 

iit;c  in,  'J  I 'J. 

H|l|ll'liti'  ill.  'Jl'l. 

I'litiinli  ill.  -!'• 

chiiriH'lir  of  iiriin'  in,  'Jl'l. 

«;oiiiil  in,  'JIH, 

coiiilitioii  ot'MiiiliiiT  in, 'JH. 

of   IiIoihI  ill,  'Jl  t. 

of  tiiiliii'V  in,  'Jl*. 
of  liMT  in,  'JI3. 
of  hmi;  in,  "JH. 
of  luinciiii^  in,  'Jl'5. 
of  >iil«i'ii  in,  "Jl  I 
ot  rtoiiiiu'li  in,  'J14. 
dfHiiitioii  of,  'Jll. 


iJ 


-O-JA***^  ' 


'2:M\ 


JSDKX. 


l)i;ilirlrs  iiiillilus,  dii't  in,  '2'^^^. 

ciimciiitiin  in,  -iH.  \ 

ciidlii^y  lit',  iJll. 

lmliit~  in,  '2\'2.  | 

hiniiit\  in,  'il'J. 

inllin  n<(Mit't'lii"ttti'in,'211. 

ncrviiiis  systi'in  in,  'J17- 

j)iilii.iliiu'y  "f.  -1!'- 

plilliiM>  ■'    ,  -l"^- 

jiiMUni  I,  -'-^• 

nu'c  in,  -I'-J. 

srx  ill,  2V2. 

sliiu  ill,  (MimliU"!'  "f,  -'7- 

suniir  in,  '2\'>. 

gviiiptoms  I't',  '215. 

tiv.itmHit.'f,  2-J0,--i21,2-^2, 

•>'Z;\,  224. 
ui'iiiH  in,  '215. 
DiUitiitiiiii  I't"  nn  tt'i-s,  154. 
Disloinii  h;i'iimt(iliimn,  M. 


Enilioli>in  of  ifniil  iirtory,  47. 
Emliniic  lui'nmturiii,  41. 
ctiiilogy  of,  42. 
history  of,  41. 
pnllioloj^'y  of,  42. 
proi;no.>is  of,  43. 
symptoms  of,  43. 
trriitiiii'iit  of,  43. 
Entozou  in  uriiu',  113. 
Kniiri'sis  iiocturna.  '207. 
ftiol.u:y  of,  207. 
]mili.aoi.'y  of. '207. 
ti-t'iUmiMit  of,  '208. 
Epitholium  of  tubules,  12. 
Erysipt'lrt.'-  ft->  ''HUSO  of  nephritis,  78. 

F. 

Forn'inV  ^n-runids,  12. 
Eilariii  biingiiinis  liominis,  G3. 


Koni'^n  liodios  in  MiuMer,  205. 

llilli,'no>ir<  of,  '201). 

Floating  kidney,  u:',. 

coii|;eiiiUil,  25. 

diiifjniwia  of,  '23, 
Fuiini  in  urine,  113. 


Giill-bliidder,  distended,  '24. 

Glioiim,  1'2;). 
(Jloiuerulo-nepliritis,  03. 

Ulueo-uiiii.  211. 
(Jlycoi-iiriu,  211. 
(Jly'Kieiiiiii,  223. 
Gouty  iddney,  04. 
Gruiiuliir  kidney,  94. 
(iruvid,  1'13. 

H. 

HiiMiiiitinuriii,  43. 
detlnition  of,  43. 
etiidojiV  of,  43. 
piitholntry  of,  44. 
prou;nosi<  of,  45. 
symptoms  of,  44. 
trt'iitment  of,  46. 
llicmiituriii,  30. 

detlnition  of,  30. 
endemic,  41. 
etioloiry  of,  30. 

false,  43. 

in  irnuty  pntients,  47. 

in  tubeirulosis  of  bladder,  200 

piiriisitie,  41. 

piitb'doiiy  of,  37. 

prou;nosis  of.  39. 

spurious,  43. 

stronirylus  };ii;iis  tus  causo,  41. 

pyniptoms  of,  38. 

treatment  of,  39. 
Hipnioclobinuria.  43. 
Hen.orrbage  of  bladder,  187. 


lyniLX. 


'j;]7 


Ilclll'^  \>«']<.   11. 

UoiNi'shoc  kidney,  *-5. 
llvdati.l  cy-ts  of  kidney,  VM. 
rii|iliiit'  of,  VW. 
llydniK'  of  clilond  in  iiculc  cystitis, 

lite. 
Hydro.iii'|iliron,  \i>0. 
Hydro  ii('|iliio>is,  I  ">0. 
di'liniiion  of,  loO. 
diuirnosis  of,  161. 
etiology  of,  151. 
imlholouy  of,  151. 
jifoi;no>is  of,  152. 
-ynijitonis  of,  151. 
triutinint  of,  1.52. 
HydrojH  ii'nalis,  1130. 
Hyo^uriii,  224. 
Uyperii'miii  of  kidney,  32. 

etiology  of  active.  ,32. 

of  pas'sivc,  32. 
pathology  of,  34. 
jii'ognn>is  of,  34. 
symjitoms  of,  33. 
treiitment  of,  34. 
Ilyperw-thisia  of  bliulder,  174. 
diabetes  as  cause,  175. 
etiology  of,  174. 
gouty  diathesis  in,  175. 
in  cerebral  or  spinal  disease, 

177. 
pvognaney  a.s  cause,  175. 
symptoms  of,  175. 
treatment  of,  17ti,  177,  178. 
trilieum  rcpens  for,  177. 
Ilypeninesis,  181. 
lIyi)ertrophy  of  bladder,  109. 

anatomical  appearances  of, 

201. 
concentrie,  100. 
definition  of,  109. 
eccentric,  190,  200. 
etiology  of,  109. 


Hypertrophy  of  bladder  in  diabetes, 
202. 
progno>is  of,  202. 
MMiptoms  of,  202. 
treatment  of,  202. 
varieties  of,  109. 
of  kidney,  124. 
of  ureteni,  154. 

K 

Kidney,  atrophy  of,  28,  123. 
cirrhotic,  04. 
conliaeted,  04. 
flouting,  21,  23,  25. 
gouty,  04. 
horseshoe,  2t'). 
hypenemia  of,  30. 
hypertrophy  of,  3(1,  124. 
movable,  10,  20,  25 

etiology  of,  20,  21. 
single,  20. 

weight  of,  29. 
solitary,  20. 
Kidneys,  ubsenee  of  both,  29. 
amyloid,  120. 

amemia  of,  45. 

anatomy  of,  7. 

aneurism  of,  47. 

anomalie>  of,  Ki,  17. 

arteries  of,  13. 

as))irntion  of.  155. 

blood-vessels  of,  13. 

cancer  of,  125. 

circulation  of,  13. 

collecting  tubes  of,  10. 

conge.stion  of,  32. 

cortical  portion  of,  10. 

cysts  of,  129. 

disease  of  arteries  of,  46. 

embolism  of,  47. 

exi.   lination  of,  8. 

fatty,  122. 


i,.k!rj**.»*«.^*>*'»»*^*' 


',■;«*•«;  tu—v**. 


2:jh 


isnr.x 


l',.iiii  I't',  ■-•'»• 
i^niimliir.  'M 
liaiimliniiriu  "f,  43. 
)i;iiii»lunii  <'t',  !it>. 
liy.liilHl  cysts  (if,  l!'.0. 
iiHiMsiitiiil  tissui'  of.  1-1. 
iiitfrtul)iilMr  tis-uc  of,  It. 
Kli'li«si;l..iiiiTulo-iiiiOiriti>,  ".»:'>• 

nmlt"riiiiitH'n  "''•  -•'' 
Malpi-liiii"  lioilics  lit',  10. 

tufi-.  1<» 
inraulliin   |»'rli"ii  "!'■  9- 

ini-ii''"'''""'"'''  "''  '"' 
licnialiiiii  "'i  ''0- 
IK'fVCS  i>t,   14. 
iii'W  npnwllis.  1'-''>. 
i„.ii-iii»lii.'Muiit       f;n.\vUis      of, 

I'JH. 
uuniliir  lit",  -•■ 
(iliy.-i"l'"4y  "I'l  "■ 
jici-itii'ii  III'.  ".  '"'  25. 
pynmiids  of,  10. 
ri'liitimis  of,  8. 
S-hiliicil,  i!8. 
si/.i'  of.  ^• 
Mip|ninitivi',  107. 
surtticiil  tiPiitniint  " 
tlironilmsis  of,  47. 
tis^ui's  (if,  0. 
tulicri'dltir,  1(^8. 
tumors  of,  rJ-'>. 
urinifi'i-ous  tiil)ul<'s  of.  9,  11. 
veins  of.  14 
weight  of,  8. 

L. 

Lisiiiimnts  of  bladder,  171,  172. 

M. 

Mnlf  irniiitionp  of  kidney,  25. 
of  ureter,  154. 


165. 


Muli-imnl  -rowtbs  of  kidmy    125 

etiolojiy  of.  12'- 

jintlioloiiy  ol,  12i'i. 

Hyiiii.loiiis  of,  I2i'i. 

tniilnnnt  of,  128. 
Midl>iijhiiin  Uifl-.  10. 
Minitiiriii.211. 
Mimiul   water  f..r  elimnio   <y>Utis, 

I'lH. 
Morliid  irrowtlis  in  uiiin',  •!•!■ 
Movable  kidney,  20. 

aeniiired,  1'.'. 

rhild-lieiirini:  a-  caii-e,  21. 

tMiiaciation  a-  eauM',  2-. 

etioloiiy  of,  20,  21. 

larjje  liver  as  cause,  22. 

8ea-si<'l<nes;i  aseause,  21.  25. 

treatnieiil  of,  24. 
Mucus  in  unne,  ill. 

N. 

Npplirali:i»i  S'*' 

di»i;nosis  of,  31. 

ctioloi-'y  of.  30. 
syniptosns  of,  30. 
treatment  of.  31. 
Nephrectomy,  l''i3. 
alidoTninal,  I'm. 
delinition  of,  lii3. 
ditl'erential  di»i;nosis  in,  105. 
liis'ory  of,  l'i3. 
indii'ations  for,  H'>4. 
metliod>  of,  lt;8. 
Nephritis,  73. 
ditfuse,  103. 
ijinity,  94. 
interstitial.  04. 
intertuliutar,  94. 

ditl'erential     diatcnosis     of, 

102. 
etiolosry  ot',  94. 
pathology  of,  95. 


^Ka 


i.\i>i:.\: 


2;i9 


Nc|iliritis,    iiitiTtut>iil!ir.    pmgnosis 
(.f,  luo. 
!-yiiiiitiiiiis  lit",  ',)". 

tlllltlllillt  nl',    1()0. 
J)nrcIlrliyMlUliiU^,   1(K!. 

fti<>l>f,'y  of,  lo;!. 
micrcisciiiiy  <>(,  HH. 
piiiliiilnny  111',  103. 
jiP'i;ii">i-  I't",  lOil. 
>yiii|)ti>iu-*  iif,  lOo. 
tri'i'''.iicnt  Hi'   106. 
tubu'mr,  "il. 

lU'lltO,  '*')■ 

ciitiiirliiil,  "ti. 

chn'Mie,  T'l. 

cldthini;   iti   the   troiitiiicnt 

of,  li:;. 
croupous,  T'i. 
dt'sinuimutivc,  T'i. 
dirt'iTfiitiiil     diii«no>i,<     of, 

10-'. 
diiinlics   in  the  Ireatiiifnt 

of,  00. 
dropsy  in,  85. 
etioloi,'y  of,  76,  79,  80. 
miiicnil  \vati'r>  in  tln'  tn'iit- 

mi'nt  of,  88. 
piitholojjty  of,  80,  81. 
pnL'umoniii  in,  92. 
pro;;iio-i-i  (if,  86. 
suluicnti',  76. 
synij)toins  of,  81,  8S,  85. 
trciiliiient  of,  87. 
vera,  102. 
Ncphro-lithiusis,  1"..^,  135. 
Nephro-litliotomy,  161. 
definition  of,  161. 
indiciitions  for,  161. 
McLean's,  Dr.,  case  of,  163. 
nieth-dof,  162. 
Ni'phro-plitliisis,  108- 
Nephro-pyo.si.<,  149. 


Ni'phrorrliiii;ia.  ■?6. 
Neplimnliapiiv  ,  157. 

(litillitioll  of,    1,'(7. 

llalin'.s  nirilind  of.  l.W. 

Kei'n  s,    l)r.,    iiioiiiiM;rapli    on. 

157,  l.-)H,  l.V.t. 
Tiiit'8  case  of,  158. 
Nephrotomy,  I'lO. 

di'tinition  of.  lno. 
Nerves  of  l)l;idiii.tr,  171. 
Nervous  system  in  diahot'S  inellclus, 

217. 
Neurali;i!i  of  lilaiMer,  172. 
Noetiirnai  ine  iiitiiicnc',  207. 
Nomenclature   ot'    discuse.s   of    the 

kiilni'V,  7;{. 
Noii-inaliu'iiant      mrowths     of     thu 
l.i.iilder,  12M. 
vurietiea  of,  128. 


Olistructioii  of  ureters,  153. 

Oligiiri".  2;W,  2:il. 

Oxalate  of  lime  calculi,  1.17. 


j  Paralysis  of  the  bladder,  183. 
j  Parasitic  hieinaturia,  41. 
Pelvis  of  kidney,  diseases  of,  133. 

stone  in,  13.1. 
Perfi>rati(in  of  ureters,  154. 
Pericystitis.  198. 

acute  and  infectious  diseases  as 

cause,  198. 
etioloiiy  of,  198. 
gonorrhren  a.s  c»u»e,  198. 
symjitonis  of,  198. 
tP-atinent  of,  199. 
Perinephritis,  152. 
definition  of,  152. 
etiology  of,  152. 
prognosis  of,  153. 


!l 


^mmSmm  »*  "^  rtftw*  **« 


Mi 


240 


JSDF.X. 


I'lriii'pliiiti^.  ^vtiiptiiin*  of,  l.VJ. 

Iri'iitiiiciil  of,  liJ'!' 
l>li,).lihiiU'-  ill  urine,  til. 
I'll j>ii ill >','y  c'f  kidiH'V,  7. 
I'ipraziii  in  proi-liyl-olic  tr«'iilinont 

of  rciml  oiiliMilus,  14ii. 
l»,,lycl>p-iM,  224. 
l',.lMiriu,  22  I. 
Pyilili-,  11". 

(■nliiili"-!!,  1:5!^. 
(■li.il.ij;y  "f,  147. 
J.athnl.'l,'y  of,   147. 
pniunn.sis  of,  14^<. 
rcniil  <'iilcu\i  a.s  cau.«',  147. 
syiiiptoiiis  of,  14H. 
tnwitmi'Ml  of,  148,  149. 
Pyelo-neplirosis,  149. 
I'yo-iii^i'hrnsis  14'.»- 
ilitiiiition  of,  149. 
,.tinloi:y..f,  149. 
piillioloijy  of,  149. 
gyiniitoms  of,  ioO. 
tmitiin'iit  of,  150. 
I'ynuiiiils  of  Ferrcin,  12. 
Pyuria,  71. 

diiitcnosis  of,  71. 

i'tioloi;y  of,  71. 

microscopic  appeurances  of,  72 


Itcnal  colic,  hypodermic  iiijwtions 
,.f  linclurc  of  opium  in, 
142. 
progiio.<i>  in,  140. 
trfiitmciit  of,  140. 
inudwiuacy,  230. 

S. 

Schuclio\vii'.s  tubule-.  10. 
SiL;lit  in  iliiil.ctcs  mcllitu>,  217. 
8kin  in  iliubctcs  mcllitu>,  217. 
Spiism  of  bladder,  IHl. 
Speriniilozoid-i  in  urine,  C3. 
Stone  in  Madder,  1H5. 

in  kidney,  133. 
Stronijylus  gifjas,  41. 
Subacute  cyftitis,  1H8. 
Su^ar  in  urine,  215. 
Sui'purativi'  kidney,  107. 
Surgical  kidney,  107. 

diairnosis  of,  107. 

etioloiry  of,  107. 

prognosis  of,  108. 

symptoms  of,  108. 

treatment  of,  108. 

treatment  of  kidney,  156. 


Renal  calculus  in  infants,  138. 

patliological    anatomy   of, 

137. 
prophylactic  treatment  of, 

143-147. 

symptoms  of,  137. 
colic,"  133,  138. 

collapse  in,  141. 
difl'erential     dias^nosis    of, 

140. 
enemnta  in,  142. 
excessive  vomiting  in,  142. 


Thrombosis  of  renal  vessels,  47. 
Tubercular  kidney,  108. 
diai^nosis  of,  111. 

etiology  of.  109. 

pathology  of,  109. 

proirnosis  of,  112. 

treatment  of,  112. 
Tuberculosi.s  of  bladder,  206. 

examination  of,  206. 

females  in,  206. 

hiematuria  in.  206. 

patliology  of,  206. 

primary,  206. 

treatment  of,  206. 


I 


03. 


L\Di:x. 


w 


'ruliular  ni)ihriti»,  "fi. 
Tuliules,  in||(..e'tiiii:,  12. 

ilihiti'd  Willi  .ysl-,  129. 

I'pithiliiiia  of,  12. 

of  SchiiL'li')W(i,  10. 

urinit'i  Tdiis,  10, 
Tubuliti-,  "It. 

U. 

I'm  mill.  1 1'i. 

lil.'tiMili'Ml  of,  113. 
eliolo;;}'  of,  113. 
syiiiiitoma  of,  lUi. 
tliooiii'S  of,  114. 
ti'i'iitmont  of,  118. 
Uru>ti>-i-,  147. 
Urato  of  utiimniiium,  69 
of  ciilciutn,  69. 
of  j)otH»iuiii,  59. 
of  sodium,  58,  69. 
Urates  54. 
Uri'ii,  4s,  50. 

iminiuit  of,  62. 
diiiiiimtion  of,  53. 
in  euiK'iT  of  stnnmcli,  63. 
ill  chlornsiH,  53. 
in  cbr.iMie  lUstnises,  53. 
inctva>i'  of,  62. 
Ureteritis,  153. 
Urot.TS  3(5,  153. 
atrophy  of,  164. 
cntlioteri/.ini;.  1<)5. 
diliitiition  of,  154. 
hyppi'tropliy  of,  154. 
niiilforniation  of.  154. 
obstruction  of,  153. 
{)erforation  i>f.  154. 
Uivthrorrbiiuiii,  30. 
Uretorrliiiiriii,  3i>. 
Uric  acid,  48   54,  50,  57. 
calculi.  137. 
compounds,  58. 

L  q 


I'lic  acid  ciy-tai.s,  57. 
Urine,  48. 

albiiini'n  ill,  OC). 

aiiiiiH'iiiuiii  plici-plmtcs  in,  00. 

unite  ill,  69. 
blood  in,  02. 

calcium  carbiinatu  in,  01. 
i-ulpliati'  in,  01. 
urate  ill,  59. 
(■ii>t>  in,  t>3,  04. 
ehriiiinil  cniiip..>itinii  (if,  48,  49, 

51.  52. 
chlorides  in,  54. 
color  of,  4H,  49. 
composition  of,  15. 
cystin  in,  01. 
dctiiiition  of,  48. 
deposit*  in,  60. 
curtliy  pbosphates  in,  00. 
t'lcmints  of  iiiorbid  growtli-s  in, 

03. 
f'lito/.oa  in,  03. 

fllaria  .sani^uinis  hominis  in,  03. 
fuiiLji  and  infusoria  in,  63. 
inorganic  constituent^  of,  54. 

dcjKisits  of,  60. 
leuciii  and  tyrosin  in,  01. 
niucu.s  and  pus  in,  01. 
(xlor  of,  51. 
organic  constituents  of,  52. 

deposits  of,  50. 
oxalate  of  lime  in,  59. 
pli.'Spb      -  of,  55. 
j)iitassiuin  urate  in,  69. 
jms  in,  71,  72. 

diiiLCnosis  of,  72. 
etioioiry  of,  72. 
microscopic  apjiearanco  (jf,  72. 
(piantity  of,  51. 
reaction  of,  48,  50. 
salts  of,  16. 
secretion  of,  12. 


21 


« ■  "Kf '•••  n  f^rr'-OK  *'i-^ 


■242 


iM>i:.\. 


{■run;     s(Tivti,.n    of,     rr<""     '"■'"'■ 
j)ri-.smf,  H. 
■.(•(Imntit.-'  "I",  M. 
Midimii  nriiti'  in,  '>'■>■ 
ti|i.(illi'  irmvily  "\\  tH,  "»(). 

of.  in  (liiilH'tos,  '210. 
sjuriimli'/.Kiil'^  i"i  •''•'• 
hiit;iir  ill,  -I'J- 
tiiiliiility  <>{,  •••• 
wliirc  .^ii'cnticl,  15. 


r 

4i>/,i'iiiii,  "4. 

V. 

V 
V 

fins  iif  Miul'li 

I'^icul  I'liliiili. 

.■ti..l..- 

H\  nipt 

r,  IT 
IH.V 

V   (.f 

I. 

isr>. 

.f,  185 

trt'iitinftil  1 

i;  iH'i. 

li:rinilllirill 

,  1H7 

. 

iml-v,  W>- 

i 

•f  , 


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